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Introduction:undernutrition has a profound effect on growth, development and susceptibility to infectious disease. In Africa, it was found that undernutrition is an underlying factor in around 35% of the preventable deaths of children under the age of 5 years. The first 1000 days of life is most crucial for childhood development. Undernourished children in their first 1000 days of development experience a significant reduction in brain development which cannot be regained later in life. The aim was to describe the profile and clinical picture of admitted children with undernutrition, in order to identify areas for intervention. Methods:a descriptive study design with an analytical component was used. Data for undernourished admitted children, ages 2-71 months, for the study period 2016-2017 at the study site were included in the study. Data were collected from patient files and summarised by frequencies and percentages. Results:data were collected from 172 patient files, which is > 80% of all children eligible for inclusion. Most (88.0%) of the children had a weight for age < -2 SD and 18.6% had bilateral pitting oedema. More than 80% of the children were still in their first 1000 days of life, 42.8% were born with low birth weight and 24.2% were not breastfed. Head circumference was only recorded for 16.3%. Presenting symptoms were cough, fever and diarrhoea - in line with those covered in the Integrated Management of Childhood Illness (IMCI). Conclusion:most children presented within the first 1000 days of life, making focussed interventions possible. Areas identified for intervention were babies with low birth weight and babies not breastfed. As most children presented with IMCI symptoms, nurses should also assess the nutritional status of these children in accordance with the guidelines. Lack of anthropometric measurements and poorly recorded feeding histories should be addressed.

Introduction:most maternal and 24.3% of infant deaths occur during childbirth. Interventions during childbirth may reduce maternal and neonatal deaths. TheGuidelines for maternity care in South Africa(2015) stipulates that all observations during labour should be recorded on a partogram. The objective of this study was to assess the knowledge and attitudes of nursing personnel and to evaluate their practices of completing partograms at National District Hospital, South Africa. Methods:a two-phase, quantitative, cross-sectional, descriptive study design was used. In phase 1, the knowledge and attitudes of midwives and nurses were evaluated. Midwives and nurses completed anonymous, self-administered questionnaires that assessed their knowledge and attitudes. In Phase 2, partogram practices were measured by assessing completed partograms using a data collection tick sheet. Results:twelve of the 17 nursing personnel completed the questionnaires. More than 90% of participants answered basic partogram knowledge questions correctly, but only two thirds knew the criteria for obstructive labour and just more than half that for foetal distress. Participants displayed a positive attitude toward the use of partograms. Of the 171 randomly selected vaginal deliveries during the study period, only 57.1% delivered with a completed partogram. Most elements of foetal monitoring and progress of labour scored above 80%, however, for maternal monitoring scored poorly in 26.4% of cases. Conclusion: although 71.4% of partograms scored more than 75% for completion, the critical components that influence maternal and foetal death, like the identification of foetal distress, maternal wellbeing and progress of labour, were lacking.

Background. Medical students are under immense academic stress. Campus unrest can contribute to stress and influence academic performance, social behaviour, emotional stability and financial expenses. Objectives. To investigate the effects of #FeesMustFall2016 (#FMF2016) on the 2016 3rd-year (semester 6) clinical medical students at the University of the Free State (UFS), Bloemfontein, South Africa. Methods. In phase 1 of the project, anonymous questionnaires were completed by the clinical students who experienced physical test disruption during #FMF2016. Opinions regarding academic performance, financial expenses, behaviour changes and stress levels were gathered. The students also completed a formal post-traumatic stress screening assessment. In phase 2 of the project, the academic performance of these students was compared with that of students not affected by #FMF2016. Results. Of the target population of 138 students, 87.0% completed the questionnaires. Three-quarters of the respondents reported a negative effect on academic performance, and most did not believe that the delivering of lectures on Blackboard was a good way of training. Alcohol consumption increased in 31.9% of the students. Criteria for post-traumatic stress disorder (PTSD) were met in 12.7% of students. Compared with previous and later cohorts of students there were no clear differences regarding marks, but there was a tendency towards poorer performance and more failures the next year. Conclusions. Semester 6 medical students at UFS reported that the #FMF2016 protests had a negative effect on academic, social, financial and stress aspects. PTSD was present in 12.7% of students compared with 7.8% in similar populations.

Background: Despite numerous studies and publications, there is still a common expectation that a medical assessment can confirm or rule out child sexual abuse (CSA). The truth is that CSA can never be ruled out and can seldom be confirmed on clinical grounds. Aim: The objective of this article was to suggest which aspects to consider when the expert medical witness in a CSA case needs to explain why CSA can seldom be confirmed and can never be ruled out. The importance of a sound medical and medico-legal history was discussed because the history was generally the only positive ‘finding’ of the assessment of children who have possibly been abused. Method: Authoritative sources were used to support the explanation of reasons for an absence of corroborative clinical findings in CSA, as defined by the World Health Organization. The authors structured the individual sections by providing a background on which to base the testimony. They then summarised the clinical forensic significance of the information which should be offered in the courts and which should reflect on the court records, to be taken into account in the eventual decision, which will be made by the court. Results: A guideline was provided for answering questions frequently posed to the expert witness in child abuse cases where there were no positive findings. Conclusion: A structure for the explanation of reasons for a normal clinical examination when evaluating children who may have been sexually abused may reduce the discomfort of medical witnesses and improve the quality of expert medical testimony.

Background: Illness, lack of vocabulary and unwillingness to discuss emotional distress may contribute to poor communication with children. Drawings may play a crucial role in enhancing communication with this patient group. Aim: This study aimed to describe the pictures drawn by primary school learners in the children's palliative care programme in Bloemfontein, South Africa, and to evaluate whether drawings can be used to assess emotional wellbeing. Methods: Drawings were assessed according to standardised human figure drawing guidelines and emotional indicator (EI) scales. Pictures were discussed with the child and compared with the clinical presence of depression or emotional discomfort. Results: A total of 29 pictures drawn by 20 children were assessed. Of the 20 participants, 18 were boys, with a mean age of 10.2 years, and 12 children were assessed as having clinical depression. Conclusions: The presence of two or more EIs, small pictures or pictures in dark colours may indicate clinical depression. Health professionals are advised not to try to interpret the picture, but to use the picture to enhance communication. Let the child explain the picture, rather than relying only on the assessment tool.

Background: Patient death is an event that all health care workers will face at some point. Beyond the family, the greatest emotional strain is on people who work directly with the patient and family. Bereavement overload occurs after multiple losses without time for normal grief in between. Aim: To investigate bereavement overload, its effects and related coping mechanisms of personnel working in adult medical wards. Setting: Four adult medical wards at National District Hospital, Bloemfontein. Methods: An analytical cross-sectional study design was performed with the aid of an intervieweradministered questionnaire. The target population included health care providers (13 doctors and 20 nurses), eight final-year medical students, and four administrative staff working in thefour adult medical wards at National District Hospital, during August to October 2016. Results: Half (48.9%) of the 45 participants reported bereavement overload. None of the medical students reported bereavement overload compared to 60.0% of nurses, 75.0% of administrative staff and 53.9% of doctors. Nearly two-thirds (64.5%, n = 29) stated that they suffered from compassion fatigue. The majority of participants (62.2%) used only positive coping mechanisms. The use of negative coping mechanisms correlated directly with a longer duration in the medical field. Conclusion: With a 49% prevalence of bereavement overload, it is important that support systems are in place to prevent the effects of negative coping mechanisms. The desirable outcome is that health care providers, who suffer from bereavement overload, experience compassion satisfaction and become more dedicated to the patients’ well-being without expense to themselves.

Background: According to the World Health Organization (WHO), malnutrition can be linked to 45% of deaths in children under the age of five years. The Integrated Nutrition Programme (INP) was introduced in 1994 to address malnutrition in South Africa. There had been no systematic evaluation of how well clinics perform regarding nutritional services. Malnutrition rates worsened in the Free State from 3.9% in 2009 to 10.7% in 2013. This study aimed to assess the effectiveness of the INP Supplementary Feeding Programme in primary healthcare facilities in the Mangaung University of the Free State Community Partnership Project, known as MUCPP, catchment area of Bloemfontein, Free State, in children aged six months to five years. Methods: This was a retrospective, descriptive cohort study. All children between six months and five years entering the feeding scheme between July 2014 and June 2015 at the MUCPP, which is the hub of the feeding scheme, and three primary healthcare clinics were included. Data were collected from September to November 2015 from the INP registers and captured on dataextraction forms. Results: In total, 730 children were included in the study, 38.8% at risk for malnutrition and 61.2% malnourished. Most of the children (80.7%) stopped attending before change was seen. Only 14.1% exited the INP successfully with a normal weight for age and 3.0% deteriorated despite nutrition interventions. Of all children with one or more follow-up visits, 50.4% (119/236) improved from severe malnutrition to underweight or exited at target weight. Conclusions: The follow-up of the children and the monitoring and implementation of the INP are inadequate. There is some evidence that children who attend the INP regularly benefit from the programme. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2017; DOI: 10.1080/20786190.2017.1340252

Background: The United Nations set a two-thirds reduction in child mortality between 1990 and 2015 in the Millennium Development Goals (MDGs) of 2000. The National Department of Health (NDoH) introduced strategies to achieve these MDGs, which included new vaccines, better HIV care and training of healthcare workers. This study investigated whether the strategies implemented by the NDoH decreased child mortality (MDG 4) at National District Hospital (NDH). Method: A retrospective file review was done on all children that died in NDH from 2008 to 2015. Data were collected from patient files and ChildPIP data forms. Deaths before and after the implementation of the strategies were compared. Results: A total of 209 children died during the study period. The mortality rate decreased from 47 per thousand admissions and stabilised at 15 per thousand admissions for the past five years. Deaths due to acute gastroenteritis decreased from 67% of the total to less than 40%. Pneumonia as the main cause of death decreased from 44 during the 2008–2010 period to 19 during the 2011–2015 period. More than 90% of the children who died were malnourished. There was no statistically significant improvement in the malnutrition rates during the study periods (p = 0.85). Conclusion: Child deaths decreased from one a week to one a month at NDH. Strategies to meet the MDG 4 targets, like the introduction of the Rotavirus and Pneumococcal vaccine, the scale-up of anti-retroviral treatment and Prevention of Mother to Child transmission of HIV and better Integrated Management of Childhood Illness training all contributed to the better outcome. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2017; DOI: 10.1080/20786190.2017.1317991

Background: Little is known about the long-term outcome of antiretroviral therapy (ART) for children with advanced-stage HIV. Aim: To assess the outcome in children with advanced HIV initiated on ART. The predictors for survival, general wellbeing and the role of palliative care were assessed. Methods: Patient files, retained patient records and personal follow-up were used for data collection. Data on baseline characteristics, ART treatment and progress were collected at baseline, 6, 12 and 48 months. Information regarding general wellbeing and school attendance and performance were collected. Results: 37 children were started on ART. At 48 months there were 18 known survivors and 7 known to have died. Another 12 were transferred to another programme or lost to follow-up. There was no significant difference in baseline characteristics between groups. All eligible children attended school and all received medical care. The hospice programme offered holistic care and support. Conclusions: No baseline characteristic could predict the outcome of children with advanced HIV initiated on ART. A hospice support programme can contribute to positive outcomes even when ART is initiated in children with advanced disease.

Background: Prematurity is globally the leading cause of neonatal mortality, morbidity and long-term disability. The Millennium Development Goals (MDG) of the United Nations, and specifically MDG 4, address child mortality. Neonatal mortality rates contribute to 37% of all under-five mortality, with the largest proportion (30%) due to prematurity. The overall purpose of this study was to determine factors associated with prematurity and to identify treatable and preventable causes at the Bloemfontein Academic Complex in order to decrease the morbidity and mortality associated with prematurity in line with MDG.Methods: A case control study design was used including all premature babies referred to the Kangaroo Care Unit of the National District Hospital between December 2010 and March 2011. Each baby was included with his/her mother as a pair. For each premature baby and mother pair a term baby and mother pair was included as a control. Data were collected on a data sheet from the mothers’ antenatal records, and from maternal notes as well as the neonatal follow-up and discharge notes. Data gathered included baseline characteristics, habits, diseases and medication of the mother during the antenatal period and delivery as well as baseline demographics of the babies. Results: A total of 194 mothers and 198 babies were included in the study with 109 case mothers and 85 control mothers . Pre-existing medical conditions were more prevalent in the premature group (69%) compared with the control group (27%) with p 0.0001. These conditions included hypertension, HIV disease and syphilis. Possible causes for prematurity identified in this study included teenage mothers and premature rupture of membranes.Conclusion: Risk factors identified for prematurity were: teenage mothers, pre-existing medical conditions in the mother, and preterm rupture of membranes. Smoking and alcohol consumption during pregnancy could not be identified as risk factors for prematurity. It is recommended that patients with any of the above-mentioned identified risk factors be classified as high risk for the development of prematurity and shorter follow-up intervals and more aggressive management of pre-existing medical conditions should be practised.

Background: The need for an appropriate South African triage system led to the development of the Cape Triage Score (CTS), a system to prioritise emergency departments’ workloads. This study evaluated the effectiveness of the CTS at the National District Hospital emergency department, Bloemfontein.Methods: In this retrospective, descriptive, observational study, files of adult patients triaged at the emergency department during February 2013 were randomly selected. Inclusion was subject to the availability of the files. Physiological parameter results were used to calculate the Triage Early Warning Score (TEWS). The side-room investigations and South African Triage Score (SATS) were recorded. Other information gathered included diagnosis, outcome, and times the patient was triaged and seen by the doctor.Results: A total of 396 files were included in the study. Patients, of whom 57.8% were women, were between the ages of 16–89 years. More than half (52%) of side-room investigations were omitted or inapprop...

Background: Multiple losses experienced by children is a topic on which little research has previously been completed. Therefore, a specific definition of multiple losses is unavailable. Multiple losses are traumatic for children and result in the need for intervention and support with respect to grief, loss and bereavement issues. The main goal of this study was to determine the prevalence of multiple losses children who had experienced this from birth to 18 years of age in the National District Hospital in Bloemfontein.Method: A literature search was carried out to define the concept of multiple losses experienced by children appropriate to the South African context. Thereafter, a descriptive study with an analytical component was used to gather information on multiple losses. Structured interviews with the parents or caretakers of the children at the National District Hospital were conducted by the researchers by means of a questionnaire. The interviews were conducted in English or Afrikaans.Results: A...

Background: Family Medicine became a speciality in South Africa in 2007. Postgraduate studies in Family Medicine changed from part-time Master of Family Medicine (MFamMed) to a full-time Master of Medicine (Family Medicine) [MMed(Fam)] degree, with changes in the curriculum and assessment criteria. The overall goal of this study was to evaluate the current assessment tool for extensive mini-dissertations in the postgraduate programme for Family Medicine, at the University of the Free State, and if necessary, to produce a valid and reliable assessment tool that is user-friendly.Method: An action research approach was used in this study, using mixed methods. Firstly, marks given by 15 assessors for four mini-dissertations using the current assessment tool were analysed quantitatively. In Phase 2, the regulation of the assessment bodies and the quantitative results of Phase 1 were discussed by assessors during a focus group interview, and data were analysed qualitatively. An adapted, improved assessment tool (Phase 3) was developed and re-evaluated in Phase 4.Results: The current assessment tool complied with the regulations of the assessment bodies. The scores allocated to specific categories varied with a median coefficient of variation of more than 15% in four of the possible 12 assessment categories. During the focus group interview, reasons for this were identified and the assessment tool adapted accordingly. During reassessment of the tool, individual assessors were identified as the reason for poor reliability.Conclusion: The current assessment tool was found to be valid, but was not reliable for all assessment categories. The adapted assessment tool addressed these areas, but identified lack of training and experience in the assessment of extensive mini-dissertations by certain assessors as the main reason for unreliable assessment.

Aim: This study aims to evaluate outcomes of children with advanced HIV disease who are initiated on antiretroviral therapy under multiprofessional specialist paediatric hospice care. Design: A retrospective cohort file review methodology was undertaken in a specialist paediatric hospice in South Africa. Methods: Antiretroviral therapy was initiated for children with a CD4% of less than 15% (for children under 6 years of age) or a CD4 count under 200 for children over 6 years of age. According to the World Health Organization Europe (2007) staging criteria, all children were stage 3/4 HIV disease. Multiprofessional staff provided daily tailored assessment and care. Each child was followed for 6 months. Data on mortality, CD4 count, CD4 percentage, body weight, and viral load were measured at initiation and a follow-up after 6 months. Findings: Of the 37 children initiated on ART therapy, 31 survived at 6 months. From a baseline of mean body weight 13.3kg, there was an average of 3.2kg increase (P4 counts more than doubled (P4 percentages increased from 13.6–19.4% (P

This is Part 2 of a three-part series on medico-legal documentation. Part 1 addressed the knowledge and skills necessary to complete a legal J88 document. The aim of Part 2 is to give practical guidance on completion of the J88 form in the case of assault. Part 3 will address the sexual assault section of the J88 form. As a legal document, the J88 form must be completed accurately with regard to demographic information, including the time and date of examination, to assist with interpretation of the findings. The full names of the person examined appear on the SAPS 308 form, and must be confirmed by the patient and an identification document, if available. The name of the healthcare provider must be identifiable and contact details must be stated to assist with tracing, if necessary. A complete history is important because a differential diagnosis needs be considered, and the clinical findings must be consistent with the description of the incident in terms of time, mechanism of the injury and the place at which the incident took place, as these all add to the probability that the incident occurred as disclosed. The health worker has a dual responsibility with regard to both the health and medico-legal aspects pertaining to the patient and must record these in the clinical notes. Only medico-legal aspects are recorded on the J88 form. A top-to-toe, back-to-front examination must be performed methodically, since the person may be unaware of certain injuries. The healthcare worker must write a conclusion in the space provided. Support of the history with the clinical picture is the basis for the conclusion.

SUMMARY The management of pain in pediatric palliative care (PPC) is essential. Whilst the field of pain management has developed over the years, much of what is done in PPC is based on anecdotal evidence or adult studies. This review explores recent developments in pain management in PPC, in particular the WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. Key issues discussed include the definition, assessment, pharmacological and integrative management of pain, availability of medications, education and research. Whilst advances have been made, including publication of the guidelines, significant gaps exist in terms of the evidence base, education and access to essential medications and both interdisciplinary and international collaboration are required to meet these gaps.

The management of a rape case in the emergency department is shrouded in an unacceptable level of lack of confidence. Since South Africa has a high incidence of rape, the contribution of health practitioners in addressing the crime successfully is essential. The medical management of such cases carries a high level of uncertainty with an accompanying element of not feeling in control. The intimidation associated with the responsibility of being an expert witness complicates the matter further. This article attempts to address the reluctance to get involved in medico-legal cases and emphasises the holistic management of survivors of rape. (Full text of the research articles are available online at www.medpharm.tandfonline.com/ojfp) S Afr Fam Pract 2017; DOI: 10.1080/20786190.2017.1280900

Background: Despite the fact that UNICEF declared freedom from hunger and malnutrition abasic human right in 1948, more than 20 million children were severely malnourished in 2010 and a further 170 million were stunted. Malnutrition attributes to > 50% of child deaths by potentiating infectious diseases.Objectives: The aim of this study was to determine the extent of malnutrition in Grade 1 pupils in public sector schools in Bloemfontein. An objective of the study was to identify relationships between socio-economic parameters and malnutrition.Method: Grade 1 pupils from ten public schools in Bloemfontein, selected from a random table, were included in the study. Their parents/caregivers gave informed consent and completed a questionnaire regarding baseline characteristics and feeding practices at home.The children were then weighed and measured, and the 2007 WHO Growth Reference forschool-aged children and adolescents used as reference.Results: A total of 187 children were included in the study. The combination of underweight, wasting and stunting gave an 18% prevalence of malnutrition in this study. A BMI of less than the fifth percentile occurred in 27% of the pupils. Factors positively associated withmalnutrition included: Absence of a fridge and/or running water in the house and loweducation and/or unemployment of parents. Illness in the previous month was reported by 41% of the malnourished children.Conclusion: As socio-economic factors that contribute to malnutrition are now known, teachers will be able to identify and refer children with or at risk of malnutrition and indirectly decrease child mortality.

Introduction and background: Despite national guidelines and agreed upon admission and referral criteria for children in National District Hospital (NDH), Bloemfontein, the number of children admitted with gastroenteritis (GE) has increased dramatically since December 2007. From the previous year’s Child Healthcare Problem Identification Programme (Child PIP) data the increase in GE admissions was evident in NDH. During the preceding year, 123 children were admitted for GE and during the audit period 267. The number of deaths in NDH also increased from an average of 2.25 a month over the past 3 years to 10 a month during January and February 2008. Aim: The aims of the study were: to determine the causes of death of children in NDH; to determine the relationship between nutritional status, HIV disease, laboratory results, demographic data, time of admission, duration of admission and other diseases or conditions and GE child deaths in NDH;to determine whether doctors adhered to prescribed GE treatment protocols; to determine whether nursing personnel carried out doctors’ orders as prescribed; and to identify other factors that contributed to GE deaths. Methodology: A cross-sectional study design was used. All child deaths, as well as all children admitted with GE to Ward 3 in NDH from May 2007 to April 2008 were included in the study. The first author collected the information on a cause of death form, a data form and an audit tool. As part of the quality-improvement project, 10 items were assessed to determine whether doctors adhered to treatment protocols, and 10 items were assessed to determine whether nurses adhered to nursing orders and basic nursing care. Any other factors that contributed to poor care were also noted. Results: 1. Cause of death: During this period, 49 children died, 33 (67%) due to GE, 6 (12%) due to tuberculosis (TB), 5 (10%) due to septicaemia, 4 (8%) due to pneumonia and 1 (2%) due to congenital abnormalities. Only 4.1% of the children who died were considered as normal weight for age according to their Road to Health Chart (RTHC). Regarding HIV status, 82.5% of the children who died tested HIV positive. In total, 19.4% of allGE admissions died during this one-year period. 2. GE deaths: Demographic data such as gender and age did not influence the outcome of GE. As expected, severe malnutrition, HIV-positive status and severe dehydration all contributed statistically significantly to high mortality in GE. Severe abnormalities occurred in the laboratory results of most of the children who died and indicated the severity of their disease(s). No specific organisms were cultured from stool specimens and the quality of drinking water in Bloemfontein was declared safe for human consumption. 3. Other factors that contributed to GE deaths: Medical and nursing care were of a high standard and treatment protocols were followed. Pre-admission factors such as transport, non-availability of 24-hour medical services, non-initiation of emergency treatment before referral, and caregivers not realising the severity of the disease need urgent attention to prevent further deaths. Conclusion: GE contributed to 67% of deaths in the paediatric ward of NDH. Underlying poor nutritional status and/or HIV disease were present in 96% of the GE deaths. In more than nine out of ten cases the doctors and nurses in the hospital rendered medical care in accordance with standard guidelines. Pre-admission factors need to be addressed in order to prevent more deaths.