[Show abstract][Hide abstract] ABSTRACT: To assess the impact of HIV infection and exposure on survival in critically ill children requiring resuscitation.
A 6-month descriptive prospective cohort study of all live admissions to the resuscitation room of an urban paediatric emergency department in Blantyre, Malawi.
583 children were resuscitated, of whom 401 (69%) survived to hospital discharge. 26% of all children tested positive for HIV infection (152/576), and this was highest in patients presenting with shock (66%; 162/247), clinically diagnosed septicaemia (57%; 125/218) and malnutrition (40%; 24/60). Of 152 HIV-seropositive children, 30 (20%) died within 24 h, while among 424 seronegative children 36 (8.4%) died within 24 h (p<0.001). Later deaths (>24 h) were also more common in HIV-seropositive children compared with HIV-uninfected patients (24.3% vs 12.3%; p<0.001). Survival to 24 h was 80% (122/152) and to discharge 56% (85/152) in HIV-seropositive children. In HIV-uninfected children survival to 24 h was 92% (388/424) and to discharge 79% (336/424).
Early and late case death rates are greater in HIV-seropositive than in HIV-uninfected children. 80% of HIV-infected children survived the period most influenced by the process of resuscitation, that is, the first 24 h. HIV status alone should not influence the limitation of intervention decisions in the resuscitation room when faced with a critically ill child.
Emergency Medicine Journal 10/2010; 27(10):746-9. DOI:10.1136/emj.2009.085191 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Malnutrition underlies 50% of paediatric morbidity and mortality in sub-Saharan Africa. It is important to look for the underlying causes of the malnutrition, and some clinicians have assumed that the presence of a pericardial effusion indicates underlying tuberculosis (TB). We wished to see how common pericardial effusions are in malnourished children and how their presence or size is related to peripheral oedema or the type of malnutrition of the child, HIV status or to underlying TB.
We prospectively studied a cohort of children at a regional nutritional rehabilitation unit in Malawi. Echocardiography on admission and follow-up 4 weeks later was performed. During this interval children received therapeutic feeding and any other required medical care. The children were grouped into group 1 (marasmus), group 2 (marasmus with TB), group 3 (marasmic kwashiorkor), group 4 (marasmic kwashiorkor with TB), group 5 (kwashiorkor) and group 6 (kwashiorkor with TB).
Of the 89 children who were enrolled, 28 were marasmic (eight also had TB), 29 had marasmic kwashiorkor (six with TB) and 32 had kwashiorkor (four with TB). In all the children who had a pericardial effusion, its size was greatest at presentation. The overall reduction in pericardial effusion size after 4 weeks of nutritional therapy was significant (2.9 mm change, range 0 to 8.4 mm, p = 0.002). The greatest change in pericardial effusion size was in the children with most peripheral oedema compared with those with no oedema (2.7 mm versus 1.0 mm, p = 0.017).
In severely malnourished children pericardial effusions are common, larger in children with peripheral oedema and respond to nutritional therapy alone.
Archives of Disease in Childhood 06/2008; 93(12):1033-6. DOI:10.1136/adc.2007.136747 · 2.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Emergency ultrasonography is an appealing imaging modality in paediatric emergencies, given its non-invasive nature and potential as an adjunct to physical examination in a setting where rapid decisions need to be made. This review of a case series describes the applications, versatility, and limitations of emergency physician led ultrasonography in a paediatric resuscitation room in a sub-Saharan African setting.
Emergency Medicine Journal 06/2006; 23(5):335-40. DOI:10.1136/emj.2005.028761 · 1.84 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To improve the care of children who are victims of child sexual abuse (CSA) by routinely assessing eligibility for HIV post-exposure prophylaxis (PEP) and to investigate the feasibility, safety, and efficacy of such treatment started in a paediatric emergency department in Malawi.
Children presenting to the Queen Elizabeth Central Hospital, Blantyre between 1 January 2004 and 31 December 2004 with a history of alleged CSA were assessed for eligibility for HIV PEP and followed prospectively for six months.
A total of 64 children presented with a history of alleged CSA in the 12 month period; 17 were offered PEP. The remainder were not offered PEP because of absence of physical signs of abuse (n = 20), delay in presentation beyond 72 hours from assault (n = 11), repeated sexual abuse in the preceding six months (n = 15), and HIV infection found on initial testing (n = 1). No family refused an HIV test. No side effects due to antiretroviral therapy were reported. Of the 17 children commenced on PEP, 11 returned for review after one month, seven returned at three months, and two of 15 returned at six months post-assault. None have seroconverted.
In a resource-poor setting with a high HIV prevalence, HIV PEP following CSA is acceptable, safe, and feasible. HIV PEP should be incorporated in to national guidelines in countries with a high community prevalence of HIV infection.
Archives of Disease in Childhood 02/2006; 90(12):1297-9. DOI:10.1136/adc.2005.080432 · 2.90 Impact Factor