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AIDS accounted for approximately one quarter of all deaths in South Africa in 2000 and has become the country's single biggest cause of death. (1) Paediatric HIV infection is now [...]

Background: Necrotizing enterocolitis (NEC) is the leading cause of gastrointestinal morbidity in preterm infants, and prevention and treatment strategies have remained largely unchanged over the past several decades. As understanding of the microbiome has increased, probiotics have been hypothesized as a possible strategy for decreasing rates of NEC, and several studies have noted significant decreases in rates of NEC after initiation of probiotics in preterm infants. However, a recent AAP report cited caution on the use of probiotic use in part because studies of probiotic use in ELBW infants are lacking. As our unit began routine use of probiotics for all infants <33 weeks in 2015 and we are a leading institution for intact survival of ELBW infants, we attempted to answer if probiotic use can impact the rate of NEC in VLBW and ELBW infants. Methods: We conducted a single-center retrospective chart review of infants with modified Bell's stage ≥2a NEC for the 4 years prior to and 5 years after initiation of a protocol involving routine supplementation of a multispecies probiotic to premature infants at the University of Iowa, Stead Family Children's Hospital. The primary outcome measures were rates of modified Bell's stage ≥2a NEC and all-cause pre-discharge mortality at our institution before and after initiation of routine probiotic supplementation in 2015. Results: In our institution, neither the rates of modified Bell's stage ≥2a NEC, nor the rates of all-cause mortality were significantly altered in very low birth weight (VLBW) infants by the initiation of routine probiotic use (NEC rates pre-probiotic 2.1% vs. post-probiotic 1.5%; all-cause mortality rates pre-probiotic 8.4% vs. post-probiotic 7.4%). Characteristics of our two cohorts were overall similar except for a significantly lower 5-minute APGAR score in infants in the post-probiotic epoch (pre-probiotic 8 vs. post-probiotic 6 p = 0.0316), and significantly more infants in the post-probiotic epoch received probiotics (pre-probiotics 0% vs. post-probiotics 65%; p < 0.0001). Similarly, probiotic use had no impact on the incidence of NEC when we restricted our data to only extremely low birth weight (ELBW) infants (pre-probiotics 1.6% vs post-probiotics 4.1%). When we restricted our analysis to only inborn infants, probiotics still had no impact on NEC rates in VLBW infants (1.5% pre- and 1.1% post-probiotic, p = 0.61) or ELBW infants (2% pre- and 2.1% post-probiotic, p = 0.99) Conclusions: Contrary to other studies, we found no significant difference in rates of modified Bell's stage ≥2a NEC or all-cause pre-discharge mortality in VLBW infants following routine administration of a multispecies probiotic supplement., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Juber, Boly, Pitcher and McElroy.)

Background: Despite increased national attention on misuse of prescription and nonprescription opioids for adolescents and children, little is known about opioid use in a pediatric population during hospitalization for injury. The purpose of this investigation is to describe opioid administration and magnitude of opioid exposure in the first 48 hours of hospitalization in a pediatric trauma population., Study Design: This is a secondary analysis of data collected for a randomized, prospective intervention study at 4 Midwestern children's trauma centers. Participants included children ages 10 to 17 years old, admitted to the hospital for unintentional injury. Descriptive statistics and multivariable modeling were used to characterize demographic factors and measure prevalence and magnitude of opioid use within the first 48 hours of hospitalization., Results: Among 299 participants, 82% received at least 1 opioid administration. Children had increased odds of receiving an opioid (odds ratio [OR] 4.25; 95% CI 2.16 to 8.35) for every log increase of Injury Severity Scores (ISS), yet the majority of children with minor injury (61%) also received an opioid. Children with fractures and older children had higher odds of receiving an opioid. Amount of opioid, expressed as morphine milligrams equivalent (MME), significantly increased with child age, ISS, and fracture., Conclusions: Most pediatric trauma patients received an opioid in the first 48 hours of hospitalization, although prevalence and exposure varied by age, injury, and acuity. Aggressive pain management can be appropriate for injured pediatric patients; however, study results indicate areas for improvement, specifically for children with minor injuries and those receiving excessive opioid amounts., (Copyright © 2019 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Undifferentiated embryonal sarcoma of the liver (UESL) is a rare neoplasm, and the third-most common paediatric hepatic malignancy. However, no treatment guidelines exist. No randomised, controlled trials support specific combinations of therapy., Objective: To compare presentation and management of UESL with other series, review the literature, and formulate treatment guidelines., Methods: A retrospective chart review of all hepatic malignancies was conducted from 1996 to 2007 and 5 children with UESL were identified. Management and outcomes were documented. The literature regarding treatment modalities up to September 2012 was reviewed., Results: Over a period of 11 years, 5 patients presented. All underwent surgery and 4 received chemotherapy. One received radiotherapy at relapse. Three are disease-free with follow-up of 58 - 184 months. One died after relapse, as did the patient whose family declined chemotherapy., Conclusion: The improved outcomes are consistent with the international experience and are probably related to combined treatment modalities and advances in supportive care. Pre-operative percutaneous biopsy provides no benefit if the lesion is resectable because it may not prove to be diagnostic, and may cause recurrence in the biopsy tract. If resectable, the recommended treatment is primary excision and adjuvant chemotherapy, with radiotherapy in selected cases. If unresectable, open biopsy is necessary to document histology, and neo- adjuvant chemotherapy is given prior to resection. If deemed unresectable, liver transplantation is considered.

Background: Gastroschisis is a congenital abdominal wall defect in which the intestines develop outside the abdomen and are exposed to amniotic fluid. When the defect is small, lymphatic, venous, and intestinal obstruction may occur and contribute to the formation of intestinal edema, atresia, ischemia, and a thick inflammatory peel. Treatment requires early coverage of abdominal contents either by primary closure or by the placement of temporary Silastic silo followed by abdominal wall closure. Currently, both traditional suture closure and the sutureless plastic closure are being employed to repair the gastroschisis defect. The goal of the current study is to evaluate plastic closure. We predict no difference will be found in clinical outcomes between plastic closure and traditional suture closure., Methods: A retrospective review of 80 patients treated between 2000 and 2009 was performed. Plastic closure was used in 52 (65%) and traditional suture closure in 28 (35%) babies. The surgical procedure was determined by surgeon preference. Of the 31(39%) babies who required silos, 15 (19%) were treated with plastic closure and 16 (20%) underwent traditional closure. We collected the following demographic data and clinical progression data. Using SAS 9.2 (SAS Institute Inc, Cary, NC), we conducted linear regression, logistic regression, and time to event models to compare the following outcomes: days on ventilator, days to start enteral feeds, days to reach goal enteral feeds, days on total parenteral nutrition, hospital charges, duration of stay, mortality, and complications., Results: The mean duration of follow-up was 11.4 months. Patients spent an average of 6 days on the ventilator. There were 2 mortalities. A multivariate analysis demonstrated that no differences were found between the 2 closures with most of the outcomes; however, when compared with traditional suture closure, those babies treated with plastic closure spent 4 days fewer days on the ventilator (P < .01). Those babies who underwent suture closure were more likely to have an infection or sepsis (odds ratio, 5.15; P < .001). When the entire cohort was considered, no significant difference was found between plastic and suture closure in time to start feeds, time to reach goal feeds, time on parenteral nutrition, hospital charges, duration of stay, or complications. Ventral hernias were noted in 46 (58%) patients, 32 (62%) after plastic closure and 14 (50%) after suture closure (P = .32). Hernia repair was required in 16 (20%) patients, 11 (21%) after plastic closure, and 5 (18%) after traditional repair (P = .32). In the silo cohort, children treated with plastic closure required 7.5(P < .01) fewer days to start enteral feeds than those treated with suture closure., Conclusion: Plastic closure of abdominal wall defects in gastroschisis is effective both as a primary procedure and after silo placement. A multivariate analysis shows plastic closure to be associated with fewer days of mechanical ventilation and less likelihood of developing infection or sepsis., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Purpose: Intraperitoneal bowel perforation may occur in utero as a result of a variety of abnormalities and typically results in sterile meconium ascites, pseudocysts, and/or calcification in the fetus. On the other hand, extraperitoneal bowel perforation in intrauterine life is extremely rare. The object of this report is to present our experience of prenatal extraperitoneal rectal perforation, defining the clinical presentation, management, and progress., Methods and Materials: Nine babies who were identified from 2 centers in the Republic of South Africa with fetal extraperitoneal rectal perforation are presented. The details of these babies were obtained retrospectively from the case notes., Results: All patients presented at or shortly after birth with air and meconium tracking below the pelvic floor manifesting as either an expanding, meconium-stained aerocele or with perirectal spreading sepsis. Where abdominal signs were present, laparotomy confirmed the extension of the meconium perforation into the peritoneal cavity. Management was by diverting colostomy, drainage of the perineal collection, and supportive therapy. A posterior approach to the rectum and excision of a fibrotic section of the lower rectal wall was performed in one case. One case developed rectal stenosis that was treated by dilatation before colostomy closure. In all the other cases, digital examination performed before colostomy closure ruled out significant narrowing. There was no mortality, and the site of the rectal perforation healed in all cases to leave good anorectal function after treatment., Conclusions: Fetal extraperitoneal perforation is extremely rare, but the clinical features are easily recognizable, and when appropriate therapy is instituted, the outcome is likely to be good with normal anorectal function to be expected in the long-term. The exact cause of the condition is unknown.

Pediatric human immunodeficiency virus (HIV) infection is a major and increasing burden worldwide, but particularly in sub-Saharan Africa. Coinfection with other pathogens increases the likelihood of progression of HIV/acquired immunodeficiency syndrome (AIDS), and the immunosuppressive consequences of the disease predispose to opportunistic infections that can run a fulminant course. Despite high prevalence, amebiasis has not appeared as a major source of morbidity during the HIV/AIDS pandemic. Information from recent sources, however, appears to suggest that amebiasis may indeed be a risk for individuals living with HIV/AIDS.

Introduction: Renal transplantation is established as the standard of care for end-stage renal failure (ESRF) in the developed world. In emerging nations, the appropriateness of such costly interventions has been questioned. We undertook an analysis of all renal transplants undertaken under the care of the pediatric nephrology service at the Johannesburg Hospital, South Africa, in order to establish the outcomes of a transplantation service in a resource-constrained environment in a developing country., Methods: This was a retrospective review of renal transplantation undertaken at a single teaching hospital in Johannesburg, part of the University of the Witwatersrand. Two hundred and eighty-two transplants were performed between 1984 and 2003. Demographic characteristics of the transplanted population, diagnosis, morbidity, graft survival, and mortality were recorded., Results: Overall 1-, 5-, and 10-yr graft survival was 82, 44, and 23%. Overall 1-, 5-, and 10-yr patient survival was 97, 84, and 68%. The median graft survival for all transplantation episodes was 4.38 yr; 70% of patients survive 10 yr and 54% survive 20 yr or more. Although early graft survival was good, there was a more rapid rate of graft loss than when compared to results from developed centers with much poorer results at 5 and 10 yr. Causes of ESRF show marked variation between the races, and black patients have significantly worse outcomes than others. Compared with white patients, black recipients received fewer living donor kidneys (26 vs. 10%, p = 0.0019), a greater proportion of totally mismatched organs (56 vs. 36%, p = 0.015), less pre-emptive transplantation (7 vs. 35%, p = 0.0001) and experienced a higher rate of primary non-function (13 vs. 3%, p = 0.004). Surgical complications of transplantation occurred in 9% of recipients, but rarely led to graft loss., Conclusion: Pediatric renal transplantation in Johannesburg can be accomplished with low complication rates, but medium and long-term graft survival is poor when compared with contemporary results achieved in developed countries. The difficulties of undertaking such complex, multidisciplinary interventions in a developing nation are daunting, but we believe that renal transplantation should still be the treatment of choice for all children with ESRF. The poorer outcomes in black recipients can be addressed by increasing education in our communities and expanding the pool of appropriate donors. Better institutional support would allow for improved long-term patient care.

Severe hemorrhagic cystitis can be a devastating complication of chemotherapy. Intravesical formalin may obviate the need for radical surgery in the face of failure of other conservative measures. Open instillation is favored in order to reduce the risk of complications.

Appendico-cutaneous fistulae are rare. We describe a 12-year-old girl with cystic fibrosis (CF) and a chronically draining sinus in the right iliac fossa, found to be a primary appendico-cutaneous fistula. Misdiagnosis of right iliac fossa pain in patients with CF and the preponderance of complicated disease frequently lead to manifestations of appendicitis rarely seen in usual clinical practice.