Thirty-four children under the age of 3 years with septic arthritis presented to Mukinge Hospital between 1 January 1992 and 31 March 1993. Twenty-six of these cultured Salmonella spp. The salmonella group comprised 17 males and 9 females with an average age of 10 months. Most patients were anaemic and all were under 50th centile for weight. The commonest presentation was swelling, pyrexia and non-use of the limb. The mean white cell count (WBC) was 14,000/mm3 and the mean erythrocyte sedimentation rate (ESR) was 15.8 mm/h, but in many cases both the WBC and ESR were normal. All patients were treated with drainage and antibiotics. All made a good recovery and were discharged pain free, apyrexial and using the affected joint. One patient was readmitted because of recurrent infection. Nine patients reviewed after 1 month had continued good function. We consider that malnutrition and local trauma are predisposing factors to the development of salmonella septic arthritis in a population where salmonella is endemic.

A study of 95 children referred for palliative care was carried out at Queen Elizabeth Central Hospital in southern Malawi, to determine the prevalence of different symptoms and signs. Seventy-seven percent of the children had HIV, 17% had cancer and 6% had a variety of other diagnoses. The commonest symptoms spontaneously presented by patients and carers were pain (27%) cough (22%) and diarrhoea (18%). Pain was significantly more common among children with cancer than those with HIV/AIDS. Cough, diarrhoea and mouth sores were significantly more common in those with HIV/AIDS. Many symptoms were not volunteered initially, but were revealed on direct questioning. This uncovered that 84% had a history of weight loss, 56% had fever and 51% had mouth sores. The commonest physical signs were wasting (76%), lymphadenopathy (40%) and oral candida (40%). Forty-seven percent of children with HIV had either lost their mother or had a mother who was sick. The wide range of physical symptoms and frequency of sickness or death in the children's mothers demonstrates the need for palliative care to be holistic, addressing the manifold physical, emotional and social problems associated with chronic and terminal illness.

There are too few palliative care services for children in resource poor countries. Health carers are overwhelmed with cases of acute illness that need their urgent attention, and chronically ill children with life-limiting diseases have been sidelined. The HIV epidemic in southern Africa revealed the huge needs in our own hospital, and in 2002, we started a hospital-based paediatric palliative care service. It was the first in Africa. We describe here how it developed and expanded in the ensuing years and how it has affected our staff, the children and their families in our care.

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