Red Cross War Memorial Children's Hospital Research Articles

Ventriculoperitoneal shunt failures at Red Cross War Memorial Children's Hospital.

Ventriculoperitoneal shunt (VP shunt) insertion is one of the mainstays of treatment of hydrocephalus and although very effective, a high rate of shunt failure persists globally.The purpose of the study was to quantify the ventriculoperitoneal shunt failure rate at Red Cross War Memorial Children's Hospital (RCWMCH) and assess potential factors contributing to shunt failures. A retrospective review of VP shunts done at RCWMCH between August 2015 through December 2019 was performed. Operative notes, discharge summaries and patient folders were reviewed to collect information about patient age, aetiology of hydrocephalus, index vs revision shunt, shunt system and other noticeable variables. Overall shunt failure was recorded. Univariate and multivariate models were used to determine causal relationship. Four hundred and ninety-four VP shunt operations were performed on 340 patients with 48.8% being index shunts and 51.2% revision shunts. The average patient age was 3.4months. The total VP shunt failure rate over the study period was 31.2%, with a 7.3% infection rate, 13.6% blockage and 3.6% disconnection rate. The most common aetiologies were post-infectious hydrocephalus 29.4%, myelomeningocele 19.7% and premature intraventricular haemorrhage 14.1%. Orbis-sigma II (OSVII), distal slit valves and antibiotic-impregnated catheters were used most frequently. Failure rates were highest in the revision group, 34.7% compared to 27.3% in index shunts. Sixty-five percent (65%) of the head circumferences measured were above the + 3 Z score (> 90th centile). VP shunt failure occurs most commonly in revision surgery, and care should be taken at the index operation to reduce failure risk. Surgeon level, duration of surgery, aetiology of hydrocephalus and shunt system used did not influence overall failure rates. A closer look at larger head circumferences, their effect on shunt systems and the socio-economic factors behind late presentations should be investigated further in the future.

A descriptive study of vancomycin use at Red Cross War Memorial Children's Hospital, Cape Town.

Antimicrobial stewardship principles guide the clinical use of antimicrobials, including vancomycin, but paediatric vancomycin prescribing practices have not been evaluated in South Africa. To document the use, prescribing practices and monitoring of intravenous vancomycin and the spectrum of bacteria isolated on microbiological culture in children treated with intravenous vancomycin during a 12-month period at Red Cross War Memorial Children's Hospital (RCWMCH). A retrospective audit of intravenous vancomycin use in children admitted to RCWMCH during 2019 was performed. All 158 vancomycin prescription episodes for 143 children were included. Overall usage of intravenous vancomycin was 63 days of therapy per 1000 patient days (interquartile range [IQR]: 38-72). The median starting dose was 15 mg/kg per dose (IQR: 14-15) and median daily dose was 45 mg/kg per day (IQR: 43-60). Vancomycin was prescribed as empiric (127/158, 80%) and directed (31/158, 20%) treatment. The median duration of treatment for the directed group (7 days) was longer than the empiric group (4 days) (p = 0.001). Vancomycin serum trough concentrations were performed in 65/98 (66%) episodes where vancomycin treatment exceeded 3 days, with only 16/65 (25%) of these samples obtained before the fourth dose. Prolonged antibiotic treatment of 14 days or more was not associated with Gram-positive bacteria on culture (odds ratio [OR]: 1.02, 95% confidence interval [CI]: 0.17-4.2). Dosing errors, prolonged empiric treatment and inappropriate vancomycin monitoring were problems associated with vancomycin prescriptions. The study identified multiple opportunities for improved vancomycin prescribing and monitoring. Further research and implementation of improved prescribing practices could contribute to the preservation of vancomycin as an effective antibiotic.

Lessons learned from regional training of paediatric nephrology fellows in Africa.

Access to care for children with kidney disease is limited in less well-resourced regions of the world and paediatric nephrology (PN) workforce development with good practical skills is critical. Retrospective review of a PN training program and trainee feedback from 1999 to 2021, based at Red Cross War Memorial Children's Hospital (RCWMCH), University of Cape Town. A regionally appropriate 1-2-year training program enrolled 38 fellows with an initial 100% return rate to their country of origin. Program funding included fellowships from the International Pediatric Nephrology Association (IPNA), International Society of Nephrology (ISN), International Society of Peritoneal Dialysis (ISPD), and the African Paediatric Fellowship Program (APFP). Fellows were trained on both in- and out-patient management of infants and children with kidney disorders. "Hands-on skills" training included examination, diagnosis and management skills, practical insertion of peritoneal dialysis catheters for management of acute kidney injury and kidney biopsies. Of 16 trainees who completed > 1year of training, 14 (88%) successfully completed subspecialty exams and 9 (56%) completed a master's degree with a research component. PN fellows reported that their training was appropriate and enabled them to make a difference in their respective communities. This training program has successfully equipped African physicians with the requisite knowledge and skills to provide PN services in resource-constrained areas for children with kidney disease. The provision of funding from multiple organizations committed to paediatric kidney disease has contributed to the success of the program, along with the fellows' commitment to build PN healthcare capacity in Africa. A higher resolution version of the Graphical abstract is available as Supplementary information.

Ten years' experience with bone conduction hearing aids in the Western Cape, South Africa.

Untreated conductive and mixed hearing losses as a result of middle ear pathology or congenital ear malformations can lead to poor speech, language and academic outcomes in children. Lack of access to centralised hearing healthcare in resource-constrained environments limits opportunities for children with hearing loss. Red Cross War Memorial Children's Hospital (RCWMCH) is one of only two dedicated paediatric hospitals in sub-Saharan Africa. Between 2016 and 2021, 29 children received implanted bone conduction hearing devices, and 104 children were fitted with bone conduction devices on softbands. The authors' experience at RCWMCH suggests that bone-anchored hearing devices, either fitted on softbands or on implanted abutments, can provide solutions in settings where patients have limited access to hearing healthcare and optimal classroom environments. Hearing healthcare should be accessible and delivered at the appropriate level of care to mitigate the adverse effects of hearing loss in children.Contribution:This article describes strategies employed at RCWMCH such as fitting bone conduction hearing devices on a softband immediately after hearing loss diagnosis and conducting follow-up via remote technology to make hearing healthcare more accessible to vulnerable populations.

Streamlining referral decisions for childhood poisoning: a cross-sectional study from a tertiary children's hospital in Cape Town, South Africa.

The study objectives were to report on current paediatric poisoning figures from South Africa, and to better understand this patient population to contribute suggestions for streamlining local triage and referral criteria. A retrospective review of children presenting to Red Cross War Memorial Children's Hospital (RCWMCH) with poisoning between January 2009 and December 2019 was performed. Data were extracted from the Poisons Information Centre's Clinical Poisonings Database. There were 3699 incidents, involving 3662 patients; 3011 (81%) patients were under 5 years (median 29 months, IQR 19 to 49 months). There was a slight decline in numbers over the 11-year period.Most patients were referred (n=2542, 69%), which included a greater proportion that were symptomatic (p < 0.001). There were 8 deaths (case fatality rate 0.2%).Medications were the most common single toxin group (n=1270, 38%), followed by handyman and industrial (HI) products (n=889, 27%), household products (n=451, 14%), and pesticides (n=445, 13%). There was a significant relationship between toxin type and referral patterns (p < 0.001) as well as clinical severity (p < 0.001): pesticides and HI products (paraffin, n=486/568, 86%) had a greater proportion of referrals, and pesticides more moderate to fatal poisonings (n=132/445, 30%), all due to cholinergic (organophosphates and carbamates) and formamidine pesticides.The medication subgroups anticonvulsants (n=21/78, 27%), anti-infectives (n=4/34, 12%), multi-vitamin/mineral (MVM) supplements (n=17/84, 20%), neuropsychiatric medications (n=50/350, 14%) and substances of abuse (n=13/47, 28%) had larger proportions of moderate to severe poisonings (p < 0.001), as did the small group of biological toxins (n=17/55, 31%; p < 0.001). Certain medication, pesticide, and biological toxin subgroups, should be flagged for early referral. The goal is to improve patient outcomes as well as optimize the use of limited resources.

Engaging nurses in research awareness using a new style of hospital journal club - a descriptive evaluation

BackgroundNurses, especially nurses in Africa, face barriers when trying to access and apply literature. These challenges include paywalls; complex academic language; and journal content which is hard to translate to local realities. ObjectivesTo investigate nurses' self-reported experiences of participating in a monthly hospital wide journal club at the Red Cross War Memorial Children's Hospital (RCWMCH). DesignThis descriptive study used a researcher-designed quantitative questionnaire design. The Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0) guideline were used. SettingRed Cross War Memorial Children's Hospital (RCWMCH) in Cape Town, South Africa. ParticipantsAll cadres of nurses working at the Red Cross War Memorial Children's Hospital (RCWMCH) who had attended six or more hospital journal club sessions at RCWMCH over the previous two years. MethodsA descriptive study using a researcher-designed quantitative questionnaire. Results155 participants completed the survey (96.87% response rate). Participants self-reported an improved knowledge of the main sections of a journal article (p < 0.001) and a significant increase in talking to colleagues about evidence-based nursing practice after attending journal club (p < 0.001). ConclusionsAttendance at a journal club appears to contribute to increased access to scientific literature, personal and organisational habits of reading, and collaborative exploration of clinical practice for nurses of all cadres. Innovative facilitation methods (including large-scale graphic facilitation) may contribute to efficacy and popularity of sessions.

COVID-19: Experience of a tertiary children's hospital in Western Cape Province, South Africa.

The COVID-19 pandemic necessitated rapid changes in healthcare systems and at Red Cross War Memorial Children's Hospital (RCWMCH), Cape Town, South Africa. Paediatric services in particular required adjustment, not only for the paediatric patients but also for their carers and the staff looking after them. Strategies were divided into streams, including the impact of COVID-19 on the hospital and the role of RCWMCH in Western Cape Province, communication strategies, adaptation of clinical services at the hospital, specifically with a paediatric-friendly approach, and staff engagement. Interventions utilised: (i) Specific COVID-19 planning was required at a children's hospital, and lessons were learnt from other international children's hospitals. A similar number of patients and staff were infected by the virus (244 patients and 212 staff members by 21 December 2020). (ii) Measures were put in place to assist creation of capacity at metro hospitals' adult services by accepting children with emergency issues directly to RCWMCH, as well as accepting adolescents up to age 18years. (iii) The communication strategy was improved to include daily engagement with heads of departments/supervisors by earlymorning structured information meetings. There were also changes in the methods of communication with staff using media such as Zoom, MS Teams and WhatsApp. Hospital-wide information and discussion sessions were held both on social platforms and in the form of smallgroup physical meetings with senior hospital administrators (with appropriate distancing). Labour union representatives were purposefully directly engaged to assess concerns. (iv) Clinical services at the hospital were adapted. These included paediatric-friendly services and physical changes to the hospital environment. (v) Staff engagement was particularly important to assist in allaying staff anxiety, developing a staff screening programme, and provision and training in use of personal protective equipment, as well as focusing on staff wellness. In conclusion, visible management and leadership has allowed for flexibility and adaptability to manage clinical services in various contexts. It is important to utilise staff in different roles during a crisis and to consider the different perspectives of people involved in the services. The key to success, that included very early adoption of the above measures, has been hospital staff taking initiative, searching for answers and identifying and implementing solutions, effective communication, and leadership support. These lessons are useful in dealing with second and further waves of the COVID-19 pandemic.

Profile of childhood hearing loss in the Western Cape, South Africa

ObjectivesTo describe the nature, associated risk factors and age of diagnosis for childhood hearing loss in a South African cohort from the Western Cape Province. MethodsA retrospective review of clinical data from children under six years of age with confirmed hearing loss at Red Cross War Memorial Children's Hospital (RCWMCH) was conducted between 1 January 2019 and 31 July 2019. Data collected included demographic information, type and degree of hearing loss, documented risk factors associated with hearing loss, and age of suspicion and diagnosis of hearing loss. ResultsThe study sample included 240 children with hearing loss, with a mean age of 42 months (21.8 SD; range 2–72). More than two thirds (68.3%) of the children presented with bilateral hearing loss. The majority presented with conductive hearing loss (64.6%), followed by sensorineural (28.7%) and mixed hearing loss (3.3%) or auditory neuropathy spectrum disorder (3.3%). More than half (51.8%) of the bilateral sensorineural hearing losses were of a profound degree. The most prominent risk factor for conductive hearing loss was otitis media, for sensorineural hearing loss it was a family history of childhood hearing loss, and for auditory neuropathy spectrum disorder it was hyperbilirubinaemia. Approximately one third of patients (27.1%) with sensorineural hearing loss did not have any associated risk factors. The mean age of diagnosis of permanent congenital or early-onset hearing loss was 31.4 months (22.8 SD; range 2–72), with a mean delay of nine months (13.2 SD; range 0–60) between age of suspicion and diagnosis of hearing loss (n = 93). ConclusionsThe large proportion of preventable hearing losses in this sample highlights the importance of maximising primary health care efforts to treat preventable causes timeously. Age of diagnosis of permanent congenital or early-onset hearing loss was severely delayed undermining prospects of positive outcomes through early intervention. Infant hearing screening services in the public health sector of South Africa should be prioritised alongside primary health care efforts to reduce preventable risks for hearing loss.

Hearing outcomes in children with meningitis at Red Cross War Memorial Children's Hospital, Cape Town, South Africa: A silent crisis.

Bacterial meningitis is one of the most common causes of hearing loss. Hearing loss develops within the first few days following the onset of meningitis, highlighting the importance of early audiology referrals. Post-meningitis hearing loss may lead to cochlear ossification, making traditional cochlear implantation impossible. To determine the duration of time from meningitis diagnosis to audiology referral. A second objective was to determine the prevalence and severity of meningitis-related sensorineural hearingloss (SNHL) at Red Cross War Memorial Children's Hospital (RCWMCH), a paediatric tertiary hospital in Cape Town, South Africa (SA). A retrospective folder review of all children diagnosed with meningitis and referred for audiological evaluation was conducted over an 18-month period between 1 January 2015 and 30 June 2016. Descriptive statistical methods were used for data analysis. The total number of inpatients diagnosed with unspecified meningitis at RCWMCH between January 2015 and June 2016 was 345. The total number diagnosed with bacterial meningitis was 68. Only 16 children with meningitis (23.5%) were referred to the Department of Audiology at RCWMCH over the 18-month period. Twelve children had confirmed bacterial meningitis. All the children had up-to-date immunisations. The mean (standard deviation) time from diagnosis to audiology referral was 17 weeks (16.9; range 1 - 60). The overall prevalence of hearing loss was 42.8%. Four children (28.5%) were diagnosed with severe to profound SNHL. Less than a quarter of all children diagnosed with bacterial meningitis at RCWMCH over the 18-month study period were referred to audiology. Frequent delays in referrals for audiological assessment following meningitis were noted. This may indicate a lack of awareness on the part of doctors. Healthcare practitioners need to be made aware of the need for prompt audiological testing for children with meningitis. In SA, local guidelines for early diagnosis and monitoring of hearing in children who have had meningitis should be developed in order to improve hearing outcomes.

Short-term outcomes of down-referral in provision of paediatric antiretroviral therapy at Red Cross War Memorial Children's Hospital, Cape Town, South Africa: A retrospective cohort study.

The large scale-up of paediatric HIV care necessitated down-referral of many children receiving antiretroviral therapy (ART) from Red Cross War Memorial Children's Hospital (RCWMCH), Cape Town, South Africa. Few published data exist on the outcomes of these children. To assess outcomes of children receiving ART in the first 12 months after down-referral to primary healthcare (PHC) clinics and identify determinants of successful down-referral. A retrospective cohort study of children &lt;15 years of age who initiated ART at RCWMCH and were subsequently down-referred to one of two PHC clinics between January 2006 and December 2012 was completed. Baseline characteristics of patients and caregivers as well as CD4+ counts, viral loads (VLs) and weights were collected 6 and 12 months after down-referral. Outcomes included retention in care and viral suppression. Of 116 children down-referred to the two study PHC clinics, 81.9% arrived at the designated PHC clinic and a further 8.6% continued care at other clinics, the remaining 9.5% being lost to follow-up. Of those successfully down-referred, 11.4% took &gt;8 weeks to present, possibly experiencing treatment interruption. At 12 months after down-referral, only 81.0% remained in care. No factors were associated with retention in care in multivariable analysis. For children who remained in care at the designated PHC clinics, the clinical and immunological gains achieved prior to down-referral were sustained through 12 months of follow-up, and 54.7% of this cohort had documented viral suppression at 12 months. However, if only children with VL results are considered, 75.9% (41/54) were virally suppressed 12 months after down-referral. Down-referral of children on ART is complex, with risk of loss to follow-up and treatment interruption.

Predicted v. real prevalence of the 22q11.2 deletion syndrome in children with congenital heart disease presenting to Red Cross War Memorial Children's Hospital, South Africa: A prospective study.

The 22q11.2 deletion syndrome (22qDS) has more than 180 associated phenotypic features, yet genotype-phenotype correlation remains obscure. Since many of the clinical characteristics are serious, yet treatable (including congenital heart disease), clinicians must maintain a high index of clinical suspicion to recognise a suite of co-occurring phenotypic features that suggest a diagnosis of 22qDS. Óskarsdottir's scoring schedule (the 'O score') is generally used to suggest the need for confirmatory fluorescent in situ hybridisation (FISH) testing, using the TUPLE 1 probe. An O score of two or more indicates the need for FISH testing.Objectives. A previous audit of FISH-positive results of patients with congenital heart disease at Red Cross War Memorial Children's Hospital (RCWMCH) revealed a clinical recognition rate of 1.7%. However, we were concerned that the syndrome may be under-recognised in our setting. Our aims were therefore to assess the predictive value of 'O scoring' and to accurately determine the prevalence of 22qDS in our patient population.Methods. A prospective trial of FISH testing every new patient with congenital heart disease presenting to RCWMCH was undertaken to accurately determine the prevalence of 22qDS. The results were then compared with the ability of the O score to indicate the need for FISH testing. Testing of 125 patients detected deletions in six (4.8%, 2.8 times the previously determined clinical detection rate), thereby vindicating our concern that 22qDS is under-diagnosed. Of these 125 patients, 37 had an O score of 2 or 3, yet only 6 were FISH-positive, giving the O score a positive predictive value of only 14%.Conclusion. Until a more robust alternative recognition tool is available, South African clinicians should use all clinical recognition criteria liberally to suggest the need for formal testing for 22qDS.

Short-term treatment outcomes of children starting antiretroviral therapy in the intensive care unit, general medical wards and outpatient HIV clinics at Red Cross War Memorial Children's Hospital, Cape Town, South Africa: A retrospective cohort study.

Many HIV-infected children are initiated on antiretroviral therapy (ART) during hospitalisation in South Africa (SA). No published data on these outcomes exist. To assess the short-term outcomes of children initiated on ART in the intensive care unit (ICU), general medical wards (GMWs) and outpatient HIV clinics (OHCs) at Red Cross War Memorial Children's Hospital (RCWMCH), Cape Town, SA. We conducted a retrospective cohort study of HIV-infected children aged <13 years commenced on first-line ART between January 2008 and December 2011. Outcomes included death, virological suppression and changes in CD4 count. Kaplan-Meier estimates, multivariate Cox proportional hazard ratios and logistic regression were used to estimate outcomes at 6 months. One hundred and six children were commenced on ART in the ICU, 509 in the GMWs and 127 in the OHCs; 65.7% of all children were <12 months old. Of children qualifying for rapid ART initiation according to the 2013 national treatment guidelines, 182 (24.9%) started therapy within 7 days of diagnosis. Overall mortality was 6.4% (95% confidence interval (CI) 4.9 - 8.4). Of children remaining in care at RCWMCH, 51.0% achieved a CD4 percentage ≥25% and 62.3% a viral load ≤50 copies/mL 6 months after ART initiation. Mortality was higher in the ICU cohort (13.2%) than in the GMW and OHC cohorts (5.5% and 3.9%, respectively, log-rank p=0.004). Predictors of mortality included moderate underweight (adjusted hazard ratio (aHR) 2.4; 95% CI 1.1 - 5.2), severe underweight (aHR 3.2; 95% CI 1.6 - 6.5), absence of caregiver counselling sessions (aHR 2.9; 95% CI 1.4 - 6.0) and ART initiation in the ICU (aHR 2.6; 95% CI 1.4 - 4.9). These results highlight the importance of understanding the context in which children initiate ART, when comparing outcomes in different settings.

Demographic profile of severe traumatic brain injury admissions to Red Cross War Memorial Children’s Hospital, 2006 - 2011

Paediatric traumatic brain injury (PTBI) is a major public health problem. However, recent epidemiological data for PTBI in South Africa (SA) are lacking. To establish a demographic profile of severe PTBI admissions to the Red Cross War Memorial Children's Hospital (RCWMCH) over a 5-year period, by investigating trends in annual admissions, age, sex, language, time and day of injury, and aetiology. Methods. This retrospective, descriptive, quantitative study included children admitted to the RCWMCH with severe traumatic brain injury (TBI) between June 2006 and April 2011, who required intracranial monitoring. We used the Division of Paediatric Neurosurgery's TBI database to identify cases for inclusion in the study and to gather demographic and injury information. Descriptive statistics suggested that: (i) the number of annual admissions did not vary substantially across the study period; (ii) the peak admission age was 6 years; (iii) more boys than girls were admitted; (iv) the major mechanism of injury was pedestrian road traffic accidents; and (v) most injuries occurred on weekends. These results are discussed against the backdrop of international research on PTBI and reflect the extent to which epidemiological findings on TBI in high-income countries compare with those from low- and middle-income countries such as SA. The identification of aetiological factors and the description of demographic profiles of children sustaining TBI constitutes a basis for preventative policy administration and intervention strategies in SA.

Cost comparison between powdered versus energy dense infant formula for undernourished children in a hospital setting

Summary Background & aims Ready to use (RTU) infant formulas became available for use in South African hospitals in 2005. However, a major barrier to use these formulae has been the perceived high product cost compared to the product cost of powdered infant formula (PIF). The aim of this cost comparative analysis was to determine the entire cost of these two feeding models. Methods This retrospective cost analysis used patient data generated from the Red Cross War Memorial Children Hospital (RCWMH), Cape Town, South Africa from 2007 to 2008. The annual cost of administering an energy dense RTU infant feed was compared to a fortified PIF, using published data of undernutrition at 34%. Only direct costs associated with the preparation and delivery were included in the analysis. Results The fortified PIF versus RTU for 1 day per undernourished child cost 16.52 Euros and 19.61 Euros for the enriched PIF with sunflower and MCT oil respectively, versus the cost of the energy dense RTU feed of 12.51 Euros per day. Conclusions The decision to feed undernourished infants with enriched PIF versus energy dense RTU feed should not be based not only on the cost of the product, but also the hidden costs, as shown by this publication.

The changing trends of childhood poisoning at a tertiary children’s hospital in South Africa

Information on childhood poisoning in the developing world, including South Africa, is scarce, despite its contribution to morbidity and mortality. We describe the profile of children with exposures and poisonings presenting to Red Cross War Memorial Children's Hospital (RCWMCH) in Cape Town, South Africa, from 2003 to 2008 and compare the trends of causative agents over the past two decades. Cases were identified by review of the RCWMCH case records. Of the total incidents (N=2 872), paraffin (kerosene) was the commonest agent (n=692, 24%) with 124 poisonings including two deaths. Drugs were the most common toxin group (n=988, 34%), including 139 single-drug poisonings with 5 deaths; 4 associated with traditional medicine use. Household cleaning product incidents (n=302, 10%) resulted in 29 single product poisonings with no deaths. Pesticide incidents (n=311, 10%) included 6 deaths; 203 (65%) incidents were due to organophosphates or carbamates. The suburban distribution of the main toxin groups varied. Comparing 1987 and 2008, the number of incidents decreased from 1 116 to 447; drug and paraffin incidents decreased respectively (from 673 to 150 and from 332 to 87), household cleaning products and cosmetics increased (21 to69) and pesticide incidents increased (7 to 69). Despite a decrease in the overall number of incidents over two decades at RCWMCH, paraffin and drugs remain the principal agents responsible for paediatric exposures and poisonings, with increasing incidents due to household cleaning products and pesticides. Identification of these toxin groups coming from specific suburbs allows for targeted prevention initiatives.

Pesticide poisonings at a tertiary children's hospital in South Africa: an increasing problem

Context. Exposure of children to pesticides and overt poisoning are an increasingly important problem in South Africa. Objective. This study describes the profile of acute paediatric pesticide exposures and poisonings presenting to Red Cross War Memorial Children's Hospital (RCWMCH) in Cape Town South Africa from 2003 to 2008, identifies those poisonings due to illicit pesticides sold on the streets (“street pesticides”) and assesses the number of incidents in which the statutory requirement of notification to the local health authority is met. Methods. Cases were identified by review of the RCWMCH case and notification records and the local health authority notification records. Results. There were 306 patients with 311 incidents of acute pesticide exposure or poisoning. This represents 11% of all paediatric exposures and poisonings (N = 2868) seen over the 6-year period. The number of pesticide incidents increased annually. Two hundred seventy-eight (91%) children were under 6 years old and 164 (54%) were males. Two hundred seventeen (70%) patients came from six socio economically diverse suburbs in the Cape Town Metropole, each of which ranges from informal settlements with extreme poverty to formal housing with lower to middle class populations. There was a summer predominance of acute pesticide exposures and poisonings. The commonest group of pesticides were 203 cholinergics (includes organophosphates and carbamates), 35 anticoagulants and 45 unknowns. One hundred incidents were classified as exposures as they were asymptomatic. Two hundred eleven symptomatic incidents, termed pesticide poisonings, required admission; 121 to High Care or Intensive Care Unit (ICU). The median length of stay in hospital was 3 days (range 0–52). There were 6 (2%) deaths. The large group of cholinergic exposures and poisonings (203) required 195 (96%) admissions; 120 (59%) to High Care or ICU. Of the 44 “street pesticide” exposures and poisonings, 33 were cholinergic poisonings and 21 required High Care or ICU. Eighty-seven (41%) of 211 poisonings requiring notification were recorded at the local health authority; all were instances of cholinergic poisoning. Conclusion. The increasing number and the morbidity and mortality of acute paediatric pesticide exposure and poisoning is of great concern. Furthermore, the magnitude of the problem is masked by inadequate notification with the relevant health authorities.

Relationships, trust, decision-making and quality of care in a paediatric intensive care unit

To assess the care-giving practices of health-care practitioners in the paediatric intensive care unit (PICU) through their qualitative insights, reflections and experience in participatory action research. Qualitative research in the form of 'participatory action research' was used to gather data from three sources within the unit: focus groups within disciplines, observations within the PICU, and semi-structured interviews. All staff members were active collaborators and equal stakeholders in the decision-making process, research and feedback. The paediatric intensive care unit (PICU) of the Red Cross War Memorial Children's Hospital (RCWMCH). All staff members from various disciplines working in the PICU. Staff members described problems with respect to relationships, trust and decision-making within care-giving practices. The study qualitatively describes how poor communication amongst staff members in respect of relationships and decision-making impacted on trust and how this tended to compromise care-giving practices in the PICU. The data suggested that this was more evident in informal rather than formal clinical decision-making procedures. The strength of the study was that the participatory action design in the research allowed staff members to address the very dynamics that they themselves cited as problematic.