Red Cross Children Research Articles

Incidence and patterns of childhood burn injuries in the Western Cape, South Africa

The current study describes the epidemiology and patterns of moderate to severe childhood burn injuries in the Western Cape province in South Africa. Burn injuries sustained by children aged 12 years and younger and registered over January 1999 to December 2000 at the Red Cross Children’s Hospital in the Western Cape are analysed ( n=1201). Differences in risk distribution between different segments of the population are measured and typical injury patterns are identified. The results show that burn injury incidence is particularly high for toddlers (15.8/10 000 child-years/c-y) and infants (14.6/10 000 c-y) for boys (7.0/10 000 c-y), and for African children (11.4/10 000 c-y). Burn injury incidence is highest in winter (1.7/10 000 c-y) but only significantly greater than the rate in summer (1.3/10 000 c-y). Further, four burn injury patterns are identified, and labeled ‘infant scalding’, ‘toddler scalding’, ‘injuries among older children with an over-representation of flame-related burns’ and ‘other causes of burns sustained to the head and neck region’. In sum, the risk of burn injury is higher in younger children. Differences between genders were more pronounced among younger and older age groups. Differences between population groups are more important in magnitude than in nature. The patterns identified can stimulate further research and development into the household product and environmental contributors to childhood burn injury.

Inhuman shields--children caught in the crossfire of domestic violence.

Child abuse is a worldwide scourge. One of its most devastating manifestations is non-accidental head injury (NAHI). This is a retrospective chart review of children presenting to the Red Cross Children's Hospital trauma unit with a diagnosis of NAHI over a 3-year period. Sixty-eight children were included in the study and 2 different groups were identified. Fifty-three per cent of the children were deliberately injured (median age 2 years), while 47% were allegedly not the intended target of the assailant (median age 9 months). The assailant was male in 65% of the intentional assaults and male in 100% of the unintentional assaults, with the intended adult victim female in 85% of the latter cases. Overall, 85% of the assaults were committed in the child's own home. The high proportion of cases in which a young child was injured unintentionally suggests that these infants effectively become shields in assaults committed by adults. In this context any attempts to deal with child abuse must also address the concurrent intimate partner violence.

Liver transplantation for children--the Red Cross Children's Hospital experience.

Liver transplantation for infants and children has been available in South Africa at a single centre, the only established service in Sub-Saharan Africa, for more than a decade. Current concerns have shifted from an initial target of early post-transplant survival to quality of life in the long-term. Since 1985, 225 infants and children have been assessed, with 146 accepted for transplantation. Sixty-nine have had 71 orthotopic liver transplants (OLTx). Biliary atresia was the most frequent diagnosis (54%) followed by acute liver failure (ALF) (15%). Waiting list mortality has remained high (23%), particularly for the ALF group (50%). Forty-three were reduced size transplants with donor: recipient weight ratios ranging from 2:1 to 11:1. Twenty-seven were <10 kg. Fifty (74%) survive 1 month-12 years post-transplant. Actuarial survival after 1996 since HBV core antibody positive donor livers were refused and prophylactic IV ganciclovir used has been >82%. Early post-OLTx mortality was low (5%), one primary non-function, one IVC thrombosis, one PV thrombosis, but late morbidity and mortality (20%) was mainly due to viral infection: de novo hepatitis B (five patients, three deaths), EBV-related post-transplantation lymphoproliferative disease (PTLPD) (eight patients, six deaths) and CMV disease (11 patients, five deaths). Tuberculosis prophylaxis, required in six cases, resulted in major morbidity in two and mortality in one. Poor compliance played a significant role in seven deaths. Hypertension requiring medication along with some compromise of renal function has been present in all but two patients. However, all those of school-going age (25) attend school normally and remain in good health and only three of the survivors have abnormal liver function tests. Successful liver transplantation is possible in a developing country with limited resources. Scarcity of virus-free donors (HBV and HIV) leading to waiting list mortality and infrequent re-transplantation along with long-term consequences of immunosuppression (infection, lymphoma and renal toxicity) remain problems. Intense education of the caregiver and close follow-up, particularly of those living at long distances has partly addressed the compliance problem.

News and Notes

News and Notes

The South African experience with ingestion injury in children

Introduction: The Red Cross Children's Hospital is the only children's hospital in South Africa. It has a dedicated trauma unit for all children under the age of 13 and serves a population of approximately 2 million inhabitants. As part of the Child Accident Prevention Foundation program we have kept a database of all children treated for trauma in our hospital since 1991. Presently, we have over 88,000 entries in our database. Aim: To study our experience with ingested foreign bodies in children. Materials and methods: A retrospective study was performed using the Child Accident Prevention Foundation of Southern Africa (CAPFSA) database of a total of 3677 patients presenting with foreign bodies. The hospital folders were searched using a standardised data extraction form. Only foreign bodies aspirated or ingested were included. Results: To date, 241 folders have been analysed. Demographics: Both sexes were equally affected (boys, 49%). Age ranged between 0 and 12 years, although there was only one child under the age of 1. At the age of 3 years, there was a peak in incidence (24% of all cases). Nature of ingested object: Although the objects were from a range of materials, most were metal (40%) or plastic (23%). The most commonly ingested object was a coin (28%), a ball (20%) or bone (8%). The size ranged from 0.1 to 3 cm (as measured by virtual ring), the most common size of an ingested foreign body was 0.5 cm. Anatomical site: The most common anatomical site of impaction was the nose (41%), followed by the esophagus (20%), the stomach (14%) and bowel (11%). Other anatomical sites included hypopharynx, nasopharynx, bronchus, larynx and oral cavity. Severity of symptoms: Only 0.4% of our cases were assessed as being severe, 14% as moderate, and 44% as mild. Forty-two percent had no symptoms. Removal: Fifty-seven percent of ingested foreign bodies were removed surgically, 19% were left in situ, 14% spontaneously dislodged and only 1% was removed by Foley catheter manipulation. Conclusion: A presentation with a foreign body is quite common in our patient population, representing approximately 4.2% of all our cases. The majority of ingested foreign bodies produced mild or no symptoms, needed surgical removal and had no complications.

The South African experience with ingestion injury in children

Introduction: The Red Cross Children’s Hospital is the only children’s hospital in South Africa. It has a dedicated trauma unit for all children under the age of 13 and serves a population of approximately 2 million inhabitants. As part of the Child Accident Prevention Foundation program we have kept a database of all children treated for trauma in our hospital since 1991. Presently, we have over 88,000 entries in our database. Aim: To study our experience with ingested foreign bodies in children. Materials and methods: A retrospective study was performed using the CAPFSA database of a total of 3677 patients presenting with foreign bodies. The hospital folders were searched using a standardised data extraction form. Only foreign bodies aspirated or ingested were included. Results: To date, 241 folders have been analysed. Demographics: Both sexes were equally affected (boys 49%). Age ranged between 0 and 12 years, although there was only one child under the age of 1. At the age of 3 years there was a peak in incidence (24% of all cases). Nature of ingested object: Although the objects were from a range of materials, most were metal (40%) or plastic (23%). The most commonly ingested object was a coin (28%), a ball (20%) or bone (8%). The size ranged from 0.1 to 3 cm (as measured by virtual ring), the most common size of an ingested foreign body was 0.5 cm. Anatomical site: The most common anatomical site of impaction was the nose (41%), followed by the oesophagus (20%), the stomach (14%) and bowel (11%). Other anatomical sites included hypopharynx, nasopharynx, bronchus, larynx and oral cavity. Severity of symptoms: Only 0.4% of our cases were assessed as being severe, 14% as moderate, and 44% as mild. Forty-two percent (42%) had no symptoms. Removal: Fifty-seven percent (57%) of ingested foreign bodies were removed surgically, 19% were left in situ, 14% spontaneously dislodged and only 1% was removed by Foley catheter manipulation. Conclusion: A presentation with a foreign body is quite common in our patient population, representing approximately 4.2% of all our cases. The majority of ingested foreign bodies produced mild or no symptoms, needed surgical removal and had no complications.

Spinal muscular atrophy in black South Africans: concordance with the universal SMN1 genotype.

Only one study has reported on the genetic basis of spinal muscular atrophy (SMA) in South African subjects. This was conducted in the Johannesburg region and has suggested that black South Africans only (indigenous Africans) differ from the norm. We have explored this further by DNA studies in 30 unrelated and racially diverse patients who reside in the Western Cape, and who were assessed as SMA subjects according to the internationally accepted inclusion criteria for SMA. These subjects were seen at the neurology clinic at Red Cross Children's Hospital in Cape Town during the period 1980-2001. Four had the type 1 form of SMA, 16 had type 2 and 10 had type 3. All patients were found to be homozygous for the loss of either exon 7 or exons 7 and 8 of the SMN1 gene. Six additional patients had anterior horn cell disease but were negative for the SMN1 gene deletion. All six had exclusion features listed in the international guidelines. This study shows that all patients from the Western Cape, which included 12 black South Africans, are no different genetically or phenotypically from the internationally recognized form of typical SMA.

Christiaan Neethling Barnard

With the sudden death of Christiaan Barnard⇓ in Cyprus on September 2, 2001, the world lost not only a pioneering cardiac surgeon but also a charismatic, if controversial, figure. On December 3, 1967, Chris Barnard led the surgical team that performed the first human-to-human heart transplant. The operation captured the public’s imagination as no procedure had before or since, and the personable Barnard rapidly became an international celebrity. Monarchs and heads of state honored him. According to French President Jacques Chirac, “Dr Barnard will remain the symbol of audacious modern medicine, able to surpass accepted ideas to bring solutions to victims of suffering and illness.” Born on November 8, 1922, in the small country town of Beaufort West in South Africa, Christiaan Neethling Barnard was one of 4 sons of a church pastor who ministered to the poor. After graduating from the local high school, Barnard entered the University of Cape Town Medical School. By his own admission, he was not an outstanding student academically, but he worked hard and graduated as a doctor in 1946. After spending a short period as a primary care physician and a resident in medicine, during which time he completed a dissertation on the treatment of tuberculous meningitis, Barnard began a busy surgical residency at Groote Schuur Hospital in Cape Town. In 1956, he received a scholarship to the University of Minnesota Medical School, where he soon was drawn to the emerging field of open heart surgery. During 2 highly productive and exciting years in the Department of Surgery under the direction of Richard Varco and C. Walton Lillehei, Barnard worked hard in both the clinic and the research laboratory. Some years later, Lillehei expressed his high regard for Barnard, particularly for his innovation, courage, “prodigious” memory, and “intensity and seriousness.” Lillehei noted …

Intrahepatic fetus-in-fetu: A case report and review of the literature

The authors report the third case since 1964 of fetus-in-fetu presenting at Red Cross Children's Hospital. A fetal liver abnormality was detected during routine antenatal ultrasound scan, and the postnatal diagnosis of an intrahepatic, multiple fetus-in-fetu was made with abdominal ultrasound scan, plain radiograph of the abdomen and computed tomography. The mass was removed surgically by hemihepatectomy when the patient was 4 months of age. Imaging and the macroscopic and microscopic appearances of the abnormality confirmed the diagnosis and amplified it to include an adjacent teratoma. Multiple small subcapsular and perimass vascular hamartomas were coincidentally discovered in the liver. Two of the 3 nodules within the amniotic-lined cavity of the intrahepatic mass individually comply with the accepted criteria for fetus-in-fetu, and the third nodule has the accepted features of a benign teratoma. The existence of multiple fetus-in-fetu and fetus-in-fetu combined with a teratoma, is recorded in the medical literature. The imaging as well as the macroscopic and microscopic features are illustrated.

Are Children with Clefts Underweight for Age at the Time of Primary Surgery?

Children with clefts, especially those with a cleft palate, have an impaired sucking mechanism and are therefore prone to nutritional problems. This study was undertaken to determine whether children with clefts of the lip and/or palate are underweight for age at the time of primary surgery. Underweight for age was defined as being less than 80 percent of expected weight for age or below the 3rd percentile as plotted on standard percentile charts. The records of all children with clefts seen at the Red Cross Children's Hospital between 1976 and 1996 were reviewed. Of these 740 records, 100 were excluded for inadequate data (47), severe systemic syndrome (27), no operation done (22), or craniofacial cleft (4). The records of 640 children were thus included; 195 (30.5 percent) were underweight for age. By comparison, only 13.7 percent of a similar group of noncleft controls (n = 872) were underweight for age. The difference between these two groups was highly significant (p < 0.01). Factors that influenced weight at the time of primary surgery were type of cleft and age at the time of surgery. Children with cleft palate, whether associated with a cleft lip or not, were found to be more underweight for age than those with an isolated unilateral cleft lip (p = 0.008). Children who had surgery after the age of 1 year were 1.5 times more likely to be underweight for age than children who had surgery under 1 year of age (p < 0.01). Children with isolated cleft palates who were underweight for age had a tendency toward a higher fistula rate (36 percent) than those of normal weight (24 percent) (p = 0.18). (Plast. Reconstr. Surg. 103: 1624, 1999.)

Are children with clefts underweight for age at the time of primary surgery?

Children with clefts, especially those with a cleft palate, have an impaired sucking mechanism and are therefore prone to nutritional problems. This study was undertaken to determine whether children with clefts of the lip and/or palate are underweight for age at the time of primary surgery. Underweight for age was defined as being less than 80 percent of expected weight for age or below the 3rd percentile as plotted on standard percentile charts. The records of all children with clefts seen at the Red Cross Children's Hospital between 1976 and 1996 were reviewed. Of these 740 records, 100 were excluded for inadequate data (47), severe systemic syndrome (27), no operation done (22), or craniofacial cleft (4). The records of 640 children were thus included; 195 (30.5 percent) were underweight for age. By comparison, only 13.7 percent of a similar group of noncleft controls (n = 872) were underweight for age. The difference between these two groups was highly significant (p < 0.01). Factors that influenced weight at the time of primary surgery were type of cleft and age at the time of surgery. Children with cleft palate, whether associated with a cleft lip or not, were found to be more underweight for age than those with an isolated unilateral cleft lip (p = 0.008). Children who had surgery after the age of 1 year were 1.5 times more likely to be underweight for age than children who had surgery under 1 year of age (p < 0.01). Children with isolated cleft palates who were underweight for age had a tendency toward a higher fistula rate (36 percent) than those of normal weight (24 percent) (p = 0.18).

Southern Africa report

One aspects of paediatric trauma medicine that really appealed to me when I entered this field just over 10 years ago, was the challenge of non-operative management of blunt injuries....

Pulmonary artery banding: adequacy and long-term outcome.

Pulmonary artery banding remains a palliative option for patients with congenital heart disease and excessive pulmonary blood flow, if there is unfavourable anatomy or frail condition. In contrast to more developed countries, our patients at Red Cross Children's Hospital, Cape Town, often present to medical services late and in poor nutritional condition. We retrospectively reviewed patients undergoing pulmonary artery banding to determine major variables that influenced long-term outcome. In a 10-year period ending June 1992, 135 consecutive patients underwent pulmonary artery banding; 89 with ventricular septal defect type non-mixing disorders, and 46 with mixing or complex disorders. The median age was 3.0 months and weight 3.5 kg with 74.8% of patients weighing less than the third percentile (NCHS adapted), and 39.3% had an additional serious medical illness. Pulmonary banding mortality was 8.1%, and was higher in neonates (22.2%), P = 0.04) but was not related to congenital disorder, associated medical illness, or associated coarctation or interrupted aortic arch. The pulmonary band was inadequate at follow-up in 28.9%, which occurred more commonly if banding was necessary before 3 months of age (41.5%, P = 0.003) but was not related to weight, congenital disorder or associated respiratory infection. Sixty patients (44.4%) have now proceeded to definitive repair with a mortality of 23.3%, which was increased if the pulmonary band was inadequate at the time of definitive repair (44.4%: P = 0.02), but was not related to the congenital disorder. An inadequate pulmonary artery band adversely affects outcome and demands further aggressive management prior to definitive repair.

The aetiology of learning disability in preschool children with special reference to preventability.

The aims of the study were to determine the aetiology of moderate and severe learning disability in preschool children in Cape Town, to consider the causes by race and to assess the degree of preventability. All children under the age of 6 years who presented to the Developmental Assessment Clinics at the Red Cross Children's Hospital with a developmental quotient of less than 50 over a 1-year period were included. The Development Assessment Clinics form a regional multidisciplinary service for the evaluation of preschool children with development disabilities. Over the 12-month period, 232 children were identified, of whom 65% were Coloured, 32% African and the remaining 3% white. This roughly corresponds with teh breakdown of births by race in the region. Regarding the aetiology, in 45% the disability was prenatal in origin, in 17% perinatal, in 9% postnatal and in a quarter it was idiopathic. In the Coloured and white children, the cause in over a half arose prenatally and in 8.3% postnatally. In contrast, the cause in less than a third of the African cases arose in the prenatal period, but 36% resulted from perinatal complications. More of the African children had multiple disabilities and additional disabilities were more common in the perinatal and postnatal categories. Forty per cent of all cases were considered to be preventable, 16% with existing knowledge and current practice. There was no significant difference in preventability between the races.

A profile of the socio-demographic background of children admitted with acute diarrhoea to the Red Cross Children's Hospital, Cape Town.

The demographic and health profile and anthropometry of 106 young children hospitalised with acute diarrhoea during winter at the Red Cross War Memorial Children's Hospital, Cape Town, is reported. Information regarding socio-economic status, feeding practices and mothers' knowledge/perceptions about the aetiology of diarrhoea and the use of Oral Rehydration Therapy (ORT) was collected on a predetermined questionnaire in English or Xhosa. The findings underline the need for an aggressive, well-targeted education programme to reduce the morbidity and mortality of vulnerable children as well as the financial drain on the hospital budget.

Comparison of total immunoglobulin G and subclass response (IgG I — IV) to Helicobacter pylori infection in children versus adults : [formula omitted]1, N. Israel 1, A. Lastovica 2, and B.D. Gold 1. Department of Pediatrics, Emory University School of Medicine, Centers for Disease Control and Prevention, Atlanta, GA 1; Dept. of Med. Microbiology, Red Cross Children's Hospital, Cape Town,

Comparison of total immunoglobulin G and subclass response (IgG I — IV) to Helicobacter pylori infection in children versus adults : [formula omitted]1, N. Israel 1, A. Lastovica 2, and B.D. Gold 1. Department of Pediatrics, Emory University School of Medicine, Centers for Disease Control and Prevention, Atlanta, GA 1; Dept. of Med. Microbiology, Red Cross Children's Hospital, Cape Town,

Long-term clinical, manometric, and histological evaluation of obstructive symptoms in the postoperative Hirschsprung's patient

One hundred seventy-eight of 326 patients had surgery for Hirschsprung's disease at Red Cross Children's Hospital (1957 to 1990) agreed to participate in a recall follow-up study. Assessment of the postoperative outcome of the Swenson, Duhamel, and Soave procedures included manometric evaluation in 43 patients by perfused-tube and balloonseries techniques. Rectal suction biopsies were performed for patients who had persistent problems with stool evacuation. One hundred fifteen of the 178 patients were more than 4 years of age, and long-term functional outcome could be assessed. Although good results were obtained in 94% overall, 16 had clinical evidence of a degree of perrsisting obstruction. Results of manometric assessment of anorectal function in these patients were not significantly different from those of 28 patients who had normal stool evacuation. A biopsy was performed in 14 of the 16 patients who had symptoms of obstruction postoperatively, and abnormal histological features were noted. There was aganglionosis in four, features of neuronal intestinal dysplasia in nine, ganlioneuromatosis of the colon in one. The results of two biopsies were entirely normal. Implications of Postoperative dysfunction after surgery for Hirschsprung's disease are discussed, and a protocol for investigation and management is proposed.

Tracheobronchial foreign bodies experience at red cross children's hospital, 1985–1990: A.G. Linegar, U.O. van Oppel, S. Hegemann, et al. S Afr Med J 82: 164–167, (September), 1992

Tracheobronchial foreign bodies experience at red cross children's hospital, 1985–1990: A.G. Linegar, U.O. van Oppel, S. Hegemann, et al. S Afr Med J 82: 164–167, (September), 1992

Acquired aganglionosis following surgery for Hirschsprung's disease: a report of five cases during a 33-year experience with pull-through procedures.

Acquired Hirschsprung's disease is a rare and controversial form of colonic aganglionosis. Little is known about its aetiology and pathogenesis. We report five cases encountered amongst 173 long-term follow-up patients treated for classical Hirschsprung's disease between 1957 and 1990 at the Red Cross Children's Hospital, Cape Town, and review the current literature. The clinical and pathological findings of the cases have been studied to explore possible aetiological mechanisms. Our cases, like most of those previously reported, developed obstructive symptoms and acquired aganglionosis in pulled-through bowel which had been previously confirmed as ganglionated. Two patients had histological evidence of hyaline fibrosis of blood vessels in the segment of bowel with acquired aganglionosis. Such fibrosis and other features attributable to regional hypoxia were not found in the other three cases. It is suggested that ischaemia with fibrosis may have a pathogenetic role in some, but not all, cases of acquired Hirschsprung's disease. A plea is made for patients developing recurrent symptoms of Hirschsprung's disease, after adequate surgical correction, to be fully studied with repeated sequential biopsies in order to gain a better understanding of the entity.

Abdominal tuberculosis in children ? surgical management

During the period 1980–1989, 95 patients, mean age 5 years, with abdominal tuberculosis (ATB) were seen at the Red Cross Children's Hospital. Eighty per cent were malnourished. Apart from fever, loss of weight, and failure to thrive, symptoms of abdominal pain, vomiting, and diarrhoea predominated. Abdominal distension (86%) and a palpable mass (57%) were the most common physical findings. Sixty-three per cent had radiological evidence of chest disease. Abdominal ultrasound was useful in identifying ascites and distribution of lymph node masses. Fifty of the 95 patients were managed on the surgical unit and the predominant involvement was: peritoneal 21, nodal 15, enteric 11, and undetermined 3. Thirteen of this group developed one or more complications — perforation (4), obstruction (7), abscess or fistulae (5), and haemorrhage (1). Surgery involved diagnostic laparotomy, extra-abdominal biopsy, and management of the complications. Emergency surgery was conservative. Definitive surgery for stricture-plasty, resection, and stoma closure was delayed at least 8 weeks to allow for chemotherapeutic effect. Uncomplicated TB responded rapidly to therapy. There were no deaths in this group. Thirty-seven of the 45 “medical” cases made an uncomplicated recovery on anti-TB therapy. Three died due to generalised disease, 5 had complications (chylous ascites 2, protein-losing enteropathy 3) and 3 had relapse of disease due to poor compliance. The morbidity and mortality of this ubiquitous disease can be greatly reduced by timely diagnosis, which often requires early recourse to diagnostic laparotomy, and appropriate surgery and supportive care for complicated disease.