Infant Care Practices at Home in the First Weeks of Life in Ibadan, South-West Nigeria

BACKGROUND

The World Health Organization recommends essential newborn care, which includes components that should be provided at home and in the community, to improve newborn outcomes. This study was carried out to assess infant care practices at home in the first week of life and how they conform to the provisions of essential newborn care.

METHODS

A total of 678 mothers who delivered their babies at Adeoyo Maternity Hospital, Ibadan were visited at home between the 8th and 10th days of delivery. Information on infant care practices with respect to hygiene, feeding, provision of warmth, eye care, cord care, immunization and health seeking behaviour was obtained.

RESULTS

Only 9.3% of the mothers washed their hands always before handling their babies, 83.3% did sometimes and 94.0% did so after diaper change. Breastfeeding was the first feed given by 93.8% of mothers, but only 21.6% of them started within one-hour of life. At the end of the first week, 71.2% were still breastfeeding exclusively. Only 16.6% of mothers bathed their newborns on the first day of life. To keep newborns warm, 82.0% shut their windows all day, and 9% lit kerosine-wick lanterns indoors. Mothers used alcohol (97.2%) and breastmilk drops (18.2%) for umbilical cord and eye care, respectively. Only 58.6% and 14.5% of babies had received any vaccination or had postnatal visit, respectively.

CONCLUSION

Infant care practices at home for newborns in Ibadan did not substantially conform to the provisions of essential newborn care and many practices were harmful. The need for supportive supervision in addition to health education for essential newborn care is indicated.

Challenges of caregivers and needs of children with parents in a Nigerian prison

BACKGROUND

Separation of a parent from the family as a result of incarceration has both short-term and long-term effects on the family, even after release from prison. This study is a report of factors and challenges of the family left to adapt to the changed circumstances of separation from parent(s) who are incarcerated.

METHODS

This was a cross sectional study carried out on 89 caregivers of children whose parents are incarcerated at the Agodi prison, Ibadan who gave informed and written consent to interview their families.

RESULTS

Most caregivers had little or no formal education (69.7%) and 67.4% are into petty trading or subsistence farming. A majority of the caregivers reported the need of schooling (85.4%), provision of food (84.3%) and medical care (71.9%) as major challenges, only 25% received any form of support to meet these needs. Twenty-nine (32.6%) respondents reported receiving financial support to provide for the child's feeding. Some caregivers 21 (23.6%), obtained loans to cope with the financial needs of the children while only 3 (3.4%) received support from family or other non-governmental organisations.

CONCLUSION

The caregivers of children of prison inmates face significant challenges in meeting the needs of feeding, health and schooling. Support structures and policies to address these gaps are required.

Co-existing sickle cell anaemia and inflammatory bowel disease: case report and review of the literature

Sickle cell anaemia (SCA) is a chronic haemolytic anaemia associated with vaso-occlusive painful crises which may affect several systems including the gastro-intestinal system, resulting in abdominal pain. The concurrence of inflammatory bowel disease and haemoglobinopathy is rare. No previously reported concurrent cases of both SCA and ulcerative colitis (UC) in sub-Saharan Africa were found in the literature. A 16-year-old girl with concurrent SCA and UC is presented. She was admitted to University College Hospital, Ibadan with a 1-year history of recurrent peri-umbilical pain and bloody stools. These symptoms were mainly attributed to SCA at the referring hospital, and she was managed for chronic tropical diarrhoea without a remarkable clinical response. This case illustrates the concurrent presentation of SCA and ulcerative colitis which led to the missed and delayed diagnosis of ulcerative colitis.

Ultrasonographic Hepatosplenic Parenchymal and Blood Flow Changes in Children with Acute Falciparum Malaria

BACKGROUND

Malaria, a major cause of morbidity and mortality in Nigerian children, is associated with biochemical, haematological, blood flow and clinical multiorgan changes, including changes in the spleen and the liver.

OBJECTIVES

To investigate hepatosplenic pathologies in a Nigerian children cohort with acute P. falciparum malaria.

METHODS

A prospective case-control study of 260 children (65 uncomplicated malaria (UCM),65 complicated malaria (CM) cases and 130 controls) aged six months to six years. All subjects had laboratory tests and hepatosplenic parenchymal and blood-flow ultrasonographic evaluation.

RESULTS

Mean splenic length was 8.13cm (95% CI: 7.84cm, 8.41cm) and 7.42cm (95% CI: 7.13cm, 7.71cm) in CM and UCM (p=0.001) respectively, liver span was significantly different in controls and CM (p<0.001); controls and UCM (p=0.014). Portal vein flow velocity was 32.5cm/s, 25.4cm/s and 26.5cm/s in controls, UCM and CM (p=<0.001 and 0.004 respectively) while splenic flow velocity was 30.7cm/s and 25.8cm/s in controls and CM (p=0.022). Splenic artery peak systolic velocity (PSV) =73.78cm/s, 66.52cm/s and 59.35cm/s (p = 0.008) among controls, UCM and CM respectively. There was significant correlation between malaria parasite (MP) density and splenic length (r =0.239, p = 0.007), splenic artery pulsatility index (PI) (r = 0.300, p = 0.001), splenic artery resistivity index (RI) (r = 0.260, p = 0.003) and liver span.

CONCLUSION

In children with acute malaria, the splenic vessels and portal vein blood flow velocities were reduced. High malaria parasite density evokes direct relationship with spleen and liver span, splenic artery RI and PI and portalvein diameter.

Long-term effects of Maternal HIV Infection and Anti-Retroviral Medications on the Hearing of HIV-Exposed Infants

BACKGROUND

The long-term effect of maternal HIV and antiretroviral medication on the hearing of HIV-exposed infants has not been well studied. We determined and compared the hearing thresholds of HIV-exposed infants with that of HIV-unexposed infants within the first month of life and at three, six and nine months of life.

MATERIALS AND METHODS

This was a Case control study of 126 HIV-exposed newborns and 121 HIV-unexposed newborns. Data collected included Socio-demographic, clinical characteristics and risk factors for hearing loss. Hearing was evaluated at newborn, 3, 6, and 9 months of life. Within and between groups analyses were done with appropriate statistics. Level of significance was P<0.05.

RESULTS

In both ears, the mean hearing thresholds of HIV-exposed infants were greater than those of the HIV-unexposed infants at baseline, 3, 6 and 9 months (P>0.05). In both groups, there was a decline in the mean hearing thresholds from baseline (new born) till 6 months of age. The highest mean threshold was recorded at 9 months. The mean hearing thresholds of infants at 3, 6, and 9 months were lower for HIV-exposed infants and higher for HIV-unexposed infants than the corresponding mean hearing thresholds measured at baseline. There was a significant strong correlation among hearing thresholds at 3, 6 and 9 months but weakly correlated with hearing thresholds at baseline.

CONCLUSION

There was a tendency towards higher hearing thresholds in HIV-exposed infants than the HIV-unexposed infants throughout the infancy period. This appears to have association with in-utero exposure to HIV.

Is there any relationship between hearing threshold levels and CD4 cell count of human immunodeficiency virus infected adults?

Background The role of viral load level and/or CD4 (Cluster of differentiation 4) cell count in the aetiopathogenesis of hearing loss in HIV infection is unclear. Therefore, we investigated the relationship between CD4 cell counts, viral load and hearing threshold of HIV (Human immunodeficiency virus) infected adults.

METHODS

This cohort audiometric study involved consecutive HIV-infected and HIV-uninfected adults as controls. Clinical data relating to hearing loss, HIV status, and highly -active antiretroviral therapy (HAART) were obtained. Audiornetric evaluation was performed. The most recent CD4 cell counts and RNA viral load-of HIV-infected participants were obtained from clinic records.

RESULTS

There were 299(66.7%) HIV-infected adults and 149(33.3%) controls with mean age of 39.64± 12.45 years and 39.60±12.45 years respectively (p=0.98). In both groups, there were more participants with left hearing loss. Mild to profound hearing loss was found in 65.9% HIV- infected participants and 53.7% controls. Majority (86.3%) of the HIV-infected participants were on HAART. The mean CD4 cell count was 654.58±289.15 in 41 HIV-infected participants not on HAART and 523.95±300.17 in 258 participants on HAART (p=0.01). Majority,- 197 (62%) HIV- infected participants with hearing loss had CD4 cell count ≤200 cells/mm3. Higher viral load significantly correlated with low CD4 cell counts (p<0.0 1; r=0. 18) and low CD4 cell count significantly correlated with high hearing threshold (p<O.01; r=0. 17).

CONCLUSION

There was a trend towards more hearing loss among the HIV-infected adults. The higher hearing threshold in those with low CD4 cell counts of <200 cells/mm3 suggests possible relationship between hearing status and severity of HIV disease.

Adolescent girls' understanding of tetanus infection and prevention: implications for the disease control in Western Nigeria

Tetanus is a major cause of morbidity and mortality in developing countries. Nigeria is aiming to eliminate tetanus by maintaining coverage of routine vaccinations for infants and pregnant women, but little attention is given to the adolescents' needs. This study assessed the understanding of adolescent girls about tetanus infection and prevention in order to provide information that may foster better policy. In this cross-sectional analytical study, 851 female adolescents were selected from eight secondary schools in Ibadan, south-west of Nigeria using a three-stage random sampling technique. A pre-tested structured questionnaire was used to obtain information on demographic and socio-economic characteristics, history of tetanus vaccination, and adolescents' knowledge of tetanus infection. Mean age of respondents was 14.3 ± 1.9 years. Only 3.1% had received tetanus toxoid injection 1 year prior to the study, most frequently following a "wound or injury" (65.4%). Though 344 (40.4%) respondents claimed that they knew about tetanus as a "serious neurological disease," only 46.5% correctly defined tetanus. Overall, the mean knowledge score was 4.8 ± 3.1 and 64.7% of the respondents had poor knowledge. Academic class was significantly associated with knowledge; higher mean score among the senior (5.3 ± 5.3) than junior classes (4.4 ± 3.2); p < 0.001. Over half (56.2%) of the adolescents disagreed with the statement that "tetanus immunization can be given to students in the school premises." There is the need to improve immunization campaigns against tetanus among adolescent girls and consider the introduction of school-based immunization programs if the elimination of maternal and neonatal tetanus is to be achieved.

Body mass composition: a predictor of admission outcomes among hospitalized Nigerian under 5 children

BACKGROUND

Malnutrition remains a public health problem and a significant contributor to morbidity and mortality among children less than 5 years, in spite of global efforts at improving nutrition.

OBJECTIVE

To examine the impact of nutritional status, by measured anthropometric indices and derived body composition, on disease outcomes in under-5 children hospitalised in an emergency unit.

METHODS

All (n=164) consecutive children aged 12-59 months admitted into the Children Emergency Ward of the University College Hospital, Ibadan over a 3 month period (May to July, 2007) had weight, length/height, mid upper arm circumference (MUAC) and skin fold thicknesses recorded. The BMI, Rohrer index, z-scores for weight-for-height and weight-for-age were calculated. Malnutrition was defined as z scores<-2. Other derived parameters included Arm-Fat-Area (AFA), Arm-Muscle-Area (AMA), Upper-Arm-Muscle-Estimate (UME), and Total-Upper-Arm-Area (TUA). Relative risk was calculated and logistic regression was used to determine which variables independently predict death.

RESULTS

There were 153 survivors and 11 deaths giving an overall death rate of 6.7%. The mean age of survivors (26.7+/-12.5 months) compared with those who died (23.1+/-12.1 months) were similar (p>0.05). The risk of death was significantly higher among the malnourished compared with the well nourished. The TUA, AMA and UME of those who died were significantly lower than survivors' (p<0.05). MUAC remained an independent predictor of death among other measured and derived anthropometric indices.

CONCLUSIONS

MUAC remains a useful anthropometric measurement for nutritional assessment and an independent predictor of survival among hospitalised under-5 children in Nigeria.

Burden of health-care of carers of children with sickle cell disease in Nigeria

Sickle cell anaemia in children is characterised by recurrent crises that frequently involve intensive medical care which may impact on the health and well-being of their carers. The psychosocial impact of sickle cell disease on 67 carers of children with sickle cell disease attending the Paediatric Haematology/Oncology clinic of the University College Hospital, Ibadan, Nigeria, was determined between February and May 2007 using a structured questionnaire adapted from an instrument earlier validated for the study of carer burden in sickle cell disease and relevant to the Nigerian culture. Data analysis was performed using the Statistical Package for Social Sciences (SPSS) version 15.0. Demographic factors as well as frequency of hospitalisations and blood transfusions were each categorised into groups and the Mann-Whitney U-test was used to test for differences in stress scores between any two groups while the Kruskal-Wallis test was used to test for differences in more than two groups. Level of statistical significance was set at P < 0.05. Family finances were adversely affected in 39 (58.2%) families. Financial stress was frequently associated with a history of two or more hospitalisations in the previous year and more so in families with more than three children. Majority (80.6%) of the carers said they had minimal or no difficulty coping with their children. There was also a significant correlation between financial stress and difficulty in parental coping. Caring for the illnesses in the children often caused disruptions in family interactions; worst in the first year after diagnosis and improved over the years. Regular assessment of psychosocial areas of need is necessary to guide provision of necessary support.

Cranial magnetic resonance imaging findings in kwashiorkor

Protein energy malnutrition (PEM) is an important public health problem in the developing countries, although it is becoming uncommon in South West Nigeria. Cerebral changes have been associated with severe PEM. This study evaluated the neurological changes using Magnetic Resonance Imaging (MRI) in Ibadan south west Nigeria. The 5 children evaluated had a median age of 16 months and all the children had brain changes compatible with cerebral atrophy. In addition two of the children had periventricular white matter changes, while one these two had mega cisterna magna in addition. Though this study did not re-evaluate the brains of these children after nutritional rehabilitation, it is possible that changes are reversible as demonstrated in earlier studies.

The economic burden of preterm/very low birth weight care in Nigeria

The care of very low birth weight (VLBW) neonates may impose an enormous burden on professional resources and finances of caregivers. This study seeks to evaluate the immediate cost of care of VLBW babies in a developing economy. Twenty-four hospital case records VLBW babies who survived till discharge over a 1 year period at the University College Hospital, Ibadan, Nigeria were reviewed. Estimates of the out of pocket costs of managing these babies were calculated. The overall cost of hospital care ranged from US$211.1 to US$1573.9. The direct (median) and indirect (median) cost of care ranged from US$80 to US$1055 (US$247.3) and US$101.0 to US$1128.1 (US$257.2), respectively. These constituted 22.8% and 3966.3% (median 133.4%) of the combined family income. In conclusion, the cost of care of the VLBW deliveries in Nigeria is very high for the level of the economy and constitutes a major financial burden on the family.

Randomised trial of artemether versus artemether and mefloquine for the treatment of chloroquine/sufadoxine-pyrimethamine-resistant falciparum malaria during pregnancy

The efficacy of artemether and artemether followed by mefloquine was evaluated in 45 pregnant women with drug resistant Plasmodium falciparum malaria during the second and third trimesters. There was prompt clinical response to both treatment regimens. The parasite and fever clearance times and the cure rate were similar in both groups. Except for the correlation between initial parasite density and fever clearance time in the artemether-mefloquine group, there was no correlation between initial parasite density and parasite or fever clearance times in the two groups. Similarly, there was no correlation between parasite and fever clearance. Both treatment regimens were well tolerated. All newborn babies of the participating women were normal at birth. Physical and neurodevelopmental assessment of the newborn babies followed up for a period varying between 6 and 36 months were within normal limits. Artemether alone or with mefloquine are effective and do not produce undue deleterious effects in pregnant patients with drug-resistant falciparum malaria during the second and third trimesters.

Choledochal cysts in African infants: a report of 3 cases and a review of the literature

Choledochal cysts are relatively rare and are an uncommon cause of cholestasis. Early diagnosis and prompt treatment can prevent complications such as cholangitis, cirrhosis and portal hypertension. This article reviews a rarely reported disease in Africans in whom only 3 cases were documented over the 18 year period in Nigeria. The 3 cases were all females with ages between less than a month and 13 months at presentation. All presented with abdominal swelling with or without jaundice or acholic stools. The use of real-time ultrasonography antenatally and postnatally aided the diagnosis in our patients. Two of the patients presented and were operated and both made full recovery confirming the importance of early surgical intervention. The third patient died, and exemplified the consequences of delayed diagnosis and treatment which occur not uncommonly in developing countries mostly because of sparse and or expensive tertiary health care facilities.

An unusual presentation of congenital bronchoesophageal fistula

We present the case of a 5-week-old neonate with multiple congenital abnormalities including a broncho-oesophageal fistula, which showed radiological features suggestive of congenital diaphragmatic hernia. Emergency limited barium swallow done was initially reported as a case of diaphragmatic hernia. Autopsy revealed pus within the right lung, and a fistulous connection between the oesophagus and an intralobar sequestrated lung. No diaphragmatic hernia or intra-abdominal organ abnormality were seen, and an occipital meningomyelocoele was also confirmed.

Vitamin A status of pre-school children in Ibadan (South West Nigeria), risk factors and comparison of methods of diagnosis

Vitamin A deficiency (VAD) and protein energy malnutrition (PEM), sharing common aetiological factors, are important public health problems in many developing, countries. A cross-sectional survey of the vitamin A status of 128 well nourished and 230 malnourished pre-school children was carried out in order to define factors associated with increased risks of VAD and also to determine the predictive values of CIC-T in identifying serum retinol of < 10 microg/dl in these children. The proportional morbidity rates of VAD defined by serum retinol concentrations (7.3%) and CIC-T (6.2%) was similar (p>0.05), and children aged < 3 years accounted for 70% of VAD cases. VAD occurred in 6.3% and 7.8% of well-nourished and malnourished children respectively. The risk of VAD was increased following measles, history of persistent diarrhoea and wasting. The predictive value of CIC-T is highly dependent on CIC-T such that abnormal and normal smears classification appears to be very robust and predictive of serum retinol of < 10 microg/dl, with sensitivity of 83.3% (95%CI: 61.8-94.5), and specificity of 73.3% (95%CI: 68.3-78.5). Judging by the proportional morbidity rate in this study, VAD appears to be a significant public health problem in both malnourished and well-nourished Nigerian children, especially in children < 3 years of age. The history of measles and persistent diarrhoea appear to increase the risk of VAD. The simplicity, sensitivity and specificity of CIC-T suggest that this procedure is a good screening tool for epidemiological survey of vitamin A status.

Tympanic thermometry in Nigerian children

Rectal and aural temperatures were recorded at the same time in 378 children aged < or = 60 months and were found to be similar across the various age groups, correlation coefficients (r) ranging from 0.61 to 0.91. The mean differences between rectal and aural temperatures varied between -0.06 and 0.25 degree C. Concordance between the two methods ranged from 88.9% to 98% across the temperature range. Tympanic thermometry is simpler, safer and quicker than rectal thermometry and these findings justify the use of aural thermometry in any busy clinical facility for children.

Hepatocellular carcinoma in Nigerian children

Childhood primary hepatocellular carcinoma is rare and accounts for less than 1% of all abdominal malignancies in children < or = 14 years of age. A review of the records of the Cancer Registry, Ibadan, Nigeria covering the period 1960-1995 was scrutinised and 19 cases of hepatocellular carcinoma (HCC) were registered, accounting for 0.49% of all abdominal malignancies over the period of review. The mean (SD) age at presentation was 10.4 (3.0) years and the duration of illness before presentation was short. All the children presented late with abdominal distension and hepatomegaly as the major clinical features. Weight loss was evident in 80% of cases, splenomegaly occurred in 50% and jaundice was present in a third of them. The prognosis was poor; all the cases died within 2 weeks of presentation in hospital. There was evidence to suggest an association between hepatitis B virus infection and HCC in all the liver tissue stained by Shikata-Orcein. This review shows that HCC, though uncommon, is important enough to be considered a possible cause of unexplained hepatomegaly in Nigerian children and that hepatitis B virus is an important aetiological factor. Though the number of cases under review is small, universal early vaccination against hepatitis B virus is necessary in Nigerian children in order to reduce the burden of chronic hepatitis B disease and hepatocellular carcinoma.

Urinary recovery of caffeine and its metabolites in healthy African children

Consumption of caffeine containing products is very popular in African children, particularly during ill health in the belief that caffeine promotes good health. This study aims to define the metabolism of caffeine, which takes place in the liver in a group of healthy Nigerian children. About 100 mg of caffeine was ingested after an overnight fast. Urine was collected before caffeine ingestion and over 12-hour periods for 36 hours in 13 healthy Nigerian children. The percentage of caffeine and metabolites recovered in urine was determined by high performance liquid chromatography. The total urinary caffeine and metabolites recovered over the 36-hour sampling period was 63.6%, with only 0.4% of the caffeine dose ingested recovered as unchanged caffeine during the same period. Insignificant amounts of 3,7-dimethyluric acid (0.2%), 3-methyluric acid (0.3%) and 1,3,7-dimethyluric acid (0.4) were recovered in the 36hour urine sample. This study also found that the N3-demethylation pathway was the principal pathway of caffeine metabolism accounting for 83.3% of the total metabolites recovered while C8-hydroxylation accounted for only 0.6% of metabolites recovered. The pattern of urinary metabolites recovered suggested that N3-demethylation is the principal pathway of caffeine metabolism in healthy African children and that small amounts of unchanged caffeine, as well as 3,7-dimethyluric acid, 3-methyluric acid and 1,3,7-dimethyluric acid were recovered during the sampling period.

The effects of acute falciparum malaria on the disposition of caffeine and the comparison of saliva and plasma-derived pharmacokinetic parameters in adult Nigerians

OBJECTIVES

The pharmacokinetics of caffeine and its dimethylxanthine metabolites were evaluated in Nigerians, for whom it is normal to consume caffeine-containing beverages during ill health and recuperation in the belief that caffeine aids early recovery from illness; however, there are no data defining the kinetics of caffeine in healthy and ill Nigerians.

MATERIALS AND METHODS

A single oral dose of 300 mg caffeine was given to ten healthy adult Nigerians and ten adults suffering from acute uncomplicated Plasmodium falciparum malaria infection. Caffeine and its dimethylxanthine metabolites were measured in plasma and saliva of healthy subjects and in plasma of patients suffering from malaria using high-performance liquid chromatography.

RESULTS

The plasma pharmacokinetics of caffeine per se in both groups was similar (P > 0.05). The maximum plasma concentration (Cmax) of paraxanthine was significantly lower (P < 0.05) in malaria (0.9 +/- 0.4 microg/ ml) than in healthy controls (1.4 +/- 0.5 microg/ml), and the paraxanthine:caffeine area under the plasma concentration time curve ratio, an index of cytochrome P450 (CYP)IA2 activity was significantly lower (P < 0.05) in malaria patients (0.5 +/- 0.1) than in healthy controls (0.3 +/- 0.2). The elimination half-life of theophylline was longer in malaria, while the area under the plasma concentration time curve of theobromine was significantly higher (P < 0.05) in malaria (7.1 +/- 3.4 microg ml(-1) h) than in healthy adults (4.1 +/- 2.2 microg ml(-1) h). Excellent correlations were found between saliva and plasma concentrations of caffeine (r2 = 0.98) with a mean saliva:plasma concentrations ratio of 0.7 +/- 0.1. The plasma concentrations (Cmax and AUC) were therefore higher than the corresponding salivary levels, so that the apparent oral clearance calculated for saliva exceeded the true oral clearance based on plasma data.

CONCLUSIONS

Acute Plasmodium falciparum malaria produced significant changes in the disposition of caffeine metabolites. Analysis of concentrations in saliva is a useful non-invasive method for monitoring the kinetics of caffeine and paraxanthine in Nigerians.

The pharmacokinetics of caffeine in Nigerian children suffering from malaria and kwashiorkor

OBJECTIVES

Caffeine-containing beverages are generally consumed by Nigerians suffering from malaria and kwashiorkor in the belief that caffeine aids early recovery from these illnesses, which are common in the tropics. However, there are no studies on the influence of these diseases on the absorption and pharmacokinetics of caffeine in Africans.

MATERIALS AND METHODS

A single oral dose of caffeine was given to five healthy children and to five and seven children suffering from malaria and kwashiorkor, respectively. Caffeine and its dimethylxanthine metabolites were measured in plasma using high-performance liquid chromatography.

RESULTS

The maximum plasma concentration (Cmax) of caffeine and the time of Cmax were similar (P > 0.05) in the three groups. However, the elimination half-life of caffeine was significantly longer in children with malaria (9.2 +/- 3.5 h) (P < 0.01) and kwashiorkor (13.1 +/- 7.9 h) (P < 0.05) than in the healthy controls (3.7 +/- 1.8 h). The total plasma oral clearance of caffeine of 4.4 +/- 1.9 ml/min/kg in healthy children was significantly higher (P < 0.01) than in those with kwashiorkor (2.0 +/- 0.9 ml/min/kg) and malaria (1.6 +/- 1.0 ml/min/ kg) (P < 0.05). Paraxanthine was the principal metabolite in all the three groups with Cmax significantly higher in healthy children (1.3 +/- 0.3 microg/ml) than in children with malaria (0.8 +/- 0.4 microg/ml) (P < 0.05) and kwashiorkor (0.3 +/- 0.1 microg/ml) (P < 0.0001). CYP1A2 activity, measured by the plasma ratios of paraxanthine: caffeine, was significantly lower in kwashiorkor and malaria.

CONCLUSIONS

This study showed that the plasma kinetics of caffeine are significantly altered in malaria and kwashiorkor, and CYP1A2 activity was lower in these two disease groups.

Comparative efficacy of chloroquine plus chlorpheniramine alone and in a sequential combination with sulfadoxine-pyrimethamine, for the treatment of acute, uncomplicated, falciparum malaria in children

One hundred and eight children with acute, symptomatic, uncomplicated, falciparum malaria were randomized to receive chloroquine (for 3 days) plus chlorpheniramine alone (for seven days) (CQ-CP group; N = 55) or, in a sequential treatment, chloroquine plus chlorpheniramine for 3 days followed, on the fourth day, by a single oral dose of sulfadoxine-pyrimethamine (25 mg sulfadoxine/kg) (CQ-CP-SP group; N = 53). The mean (S.D.) parasite-clearance time in the CQ-CP group [2.1 (0.7) days; range = 1-5 days] was similar to that in the CQ-CP-SP [2.1 (0.8) days; range = 1-5 days]. The fever-clearance times were also similar: 1.2 (0.1) days (range = 1-3 days) v. 1.1 (0.4) days (range = 1-3 days). The cure rates on days 14, 21 and 28 were 98.2%, 96.3% and 92.7%, respectively in the CQ-CP group, and 100%, 100% and 96.2%, respectively, in the CQ-CP-SP group. The rates of gametocyte carriage were low and similar (5.4% in the CQ-CP group and 3.8% in the CQ-CP-SP group) throughout the duration of the study. Both treatment regimens were relatively well tolerated, the main adverse reactions being similar: sleepiness (on day 1) and pruritus (on days 1-3). No adverse effect was attributable to SP. The results indicate that sequential treatment, for 3 days with CQ and CP, followed by a single dose of SP, is effective and well tolerated in children with acute, uncomplicated, falciparum malaria and may be an alternative treatment for CQ- and/or SP-resistant falciparum malaria. Treatment with a CQ-CP combination (CQ and CP for 3 days and then CP alone for another 4 days) is also effective but requires continuing administration after the signs and symptoms of acute malaria have disappeared.

Conjunctival impression cytology with transfer in the assessment of vitamin A status in Nigerian children

OBJECTIVE

To determine vitamin A status by conjunctival impression cytology with transfer (CIC-T) and assess its ability to predict low and deficient serum retinol concentrations.

STUDY DESIGN

CIC-T was performed on 128 healthy, well-nourished and 230 malnourished children aged under 6 years by a 3-5-second application of cellulose acetate paper to each bulbar conjunctiva followed by transfer of the adhered cells onto glass slides. The slides were stained with Alcian green 2GX, and smears were classified as normal, borderline normal, borderline abnormal and deficient. Corresponding serum retinol levels were determined in each subject.

RESULTS

The results showed that CIC-T is a simple procedure with a failure rate of 7.3% caused by tearing and agitation. The power of CIC-T to predict vitamin A status varied with both the CIC-T smear classification used and serum retinol concentration threshold. CIC-T smear classification as abnormal and normal appears to be the most robust and predictive of serum retinol, < 10 and > 10 < 20 micrograms/dL, respectively.

CONCLUSION

The simplicity, sensitivity and specificity of CIC-T suggest that this procedure is a good screening tool for epidemiologic survey of vitamin A status.

Plasma electrolytes, total cholesterol, liver enzymes, and selected antioxidant status in protein energy malnutrition

Golden and Ramdath proposed the free radical theory of kwashiorkor, suggesting that the changes seen in kwashiorkor may be the result of an imbalance between the production and safe disposal of free radicals. In malnourished children, mineral metabolism and antioxidant status need renewed attention especially in relation to cause and functional significance of the changes in concentration of these substances. In the present study, the modified Wellcome classification was used to classify the protein energy malnourished children into kwashiorkor marasmic-kwashiorkor, marasmus and underweight. Twenty-six healthy and normal children were used as controls. Standard procedures were used for the analyses of the biochemical parameters. Our results showed that plasma total cholesterol, sodium, potassium and bicarbonate, beta-carotene, retinol and uric acid were significantly lower in the malnourished group than the control group (P < 0.05), while transaminases were significantly increased in the malnourished group (P < 0.05). These findings suggest an altered electrolyte and antioxidant status in protein energy malnutrition.

Evaluation of the nutritional status of first year school children in Ibadan, Southwest Nigeria

Height for age, weight for age, and weight for height as indices of nutritional status were evaluated in 1309 pupils from different socioeconomic classes in Ibadan, Nigeria. The data obtained were compared with United States National Centre for Health Statistics (NCHS) reference population. When all the pupils studies were considered together 46.1%, 44.3% and 12.7 percent of the pupils were underweight, stunted and wasted, respectively. Both stunting and wasting were observed in 7.2% of the overall population. Only 0.6% were overweight. Generally, the proportion of stunting, underweight, wasting and both stunting and wasting increased as socioeconomic status declined, but the prevalence of overweight was higher in the 2 upper socioeconomic status schools. When all pupils were considered based on sex and irrespective of school types, significantly more male (49.5%) than female (37.4%) pupils suffered from stunting (P < 0.0001), wasting (13.8% versus 11.1% P < 0.01) and underweight (54.3% versus 35.5%: P < 0.0001). More females were overweight than males though this did not reach statistical levels (P > 0.05.) The prevalence of malnutrition in this study was higher that of previous studies in this environment, which may be a reflection of the deteriorating economic situation of Nigeria.

Arm area measurements as indices of nutritional reserves and body water in African newborns

Although application of non-invasive techniques for early evaluation of body water, calorie and protein reserves has been available for more than two decades, there is a dearth of information on the evaluation of extracellular water, protein and calorie reserves in the African newborn. A cross-sectional study of arm area measurements was undertaken in 510 term new-born infants consisting of 318 infants who were normal weight term infants (NWTI) with a mean birth weight of 2898.5 +/- 287.7 g and 192 low birth weight term infants (LBWTI) with a mean birth weight of 2176.5 +/- 194.7 g. The triceps skin fold thickness (TSF), the arm fat area (AFA), percentage of arm area (AFA%) and arm water area (AWA) were significantly greater in females than males weighing > 2500 g at birth (P < 0.05), though the mean birth weight and mid-upper arm circumference (MUAC) were similar (P > 0.05). With the exception of AFA%, all measured and calculated indices were significantly lower in LBWTI than in the NWTI irrespective of sex (P < 0.05). The measurements may aid detection of newborns at risk of developing malnutrition in an area of the world where childhood undernutrition is common.

Computerized tomography measures of brain slice area and ventricular sizes in protein energy malnutrition: a preliminary study

The brain tissues of thirty-eight Nigerian children suffering from severe protein energy malnutrition (PEM) were evaluated within 24 hours of admission by computerized tomography. The brain slice area (B.S.A.) in marasmus (10474 +/- 1270) is significantly smaller than those of marasmic-kwashiokor (10940 +/- 1284) and kwashiokor (11866 +/- 669). Similarly also the BSA of the three clinical types were smaller than those of the control (13134 +/- 1199), (P < 001). There was poor correlation of brain slice area and other parameters measured with age, but a significantly higher (mean) brain slice area was noticed in the males (11910.82) than the females (10971.67) P < 0001, in both patients and control. Marasmic-Kwashiokor showed marked feature of cerebral shrinkage compared with the other categories of PEM in all the parameters measured.

The computed axial tomography of the brain in protein energy malnutrition

Forty consecutive new cases of protein energy malnutrition were evaluated clinically and biochemically; in addition, the brain morphology was assessed by computed tomography within 24 hours of admission. Cerebral shrinkage was shown in six of 14 (42.9%) cases of marasmus, ten of 14 (71.4%) cases of kwashiorkor, and 11 of 12 (91.7%) cases of marasmic-kwashiorkor. Ventricular dilatation was demonstrated in 57.1% of marasmus cases, 71.4% of kwashiorkor cases and 91.7% of patients suffering from marasmic-kwashiorkor. However, none of the subjects studied showed any changes in the brain stem or cerebellum. Only ten returned 2 months after nutritional rehabilitation for repeat tomograms. None of these repeat tomograms showed any residual morphological changes. The study demonstrated that the brain is affected in all types of malnutrition, albeit in different proportions, but these changes are completely reversible.

Ethnic differences in nifedipine kinetics: comparisons between Nigerians, Caucasians and South Asians

Nifedipine was administered to 12 healthy Nigerian volunteers as a single oral dose of 20 mg capsule under fasting conditions. The pharmacokinetic results were compared with published data using the same protocol and analytical method for 27 Caucasians and 30 South Asians. The area under the plasma concentration-time curve (AUC) of nifedipine in Nigerians (808 +/- 250 ng ml-1 h) was significantly higher (P < 0.001) than that in Caucasians (323 +/- 116 ng ml-1 h) and the difference remained significant (P < 0.001) when corrected for body weight. The elimination half-life was also significantly higher (P < 0.01) in Nigerians (5.03 +/- 1.96 h) than in Caucasians (2.78 +/- 1.11 h). No significant differences were observed between Nigerians and South Asians in either AUC or half-life of nifedipine. The AUC of the nitropyridine metabolite was higher (P < 0.01) in Nigerians (220 +/- 51 ng ml-1 h) compared with that in Caucasians (154 +/- 56 ng ml-1 h) but the difference was not maintained when corrected for body weight. The AUC corrected for body weight and the elimination half-life of the metabolite were significantly higher in South Asians compared with those of Nigerians and Caucasians. The pharmacokinetics of oral nifedipine in Nigerians were similar to those in South Asians and therefore may also arise from a lower systemic clearance compared with Caucasians as has been reported previously for South Asians.

Hyponatraemia, birthweight and neonatal jaundice

Cord serum sodium levels were estimated in 96 full term singletons delivered by spontaneous vertex delivery. Thirty-two of these infants had cord serum sodium of less than 130 mmol/L and 64 had cord serum sodium of > or = 130 mmol/L. Serum bilirubin estimated on day 4 of life of the babies demonstrated mean unconjugated bilirubin levels of 105.7 mmol/L (S.D.:87.04) and 89.4 mmol/L (S.D.:66.18) in the hyponatraemic and normonatraemic groups respectively (P < 0.05). The study also demonstrated a higher cord sodium and lower serum unconjugated bilirubin in those babies whose mothers did not receive parenteral fluids. It is suggested that hyponatraemia should be excluded in the aetiology of neonatal jaundice.

Beliefs and attitudes of interns at Ibadan General Hospitals concerning ten medical specialties

Fifty-two interns at Ibadan general hospitals (89% response rate), participated in a study of their attitudes towards ten medical specialties. This involved completing a 40-item questionnaire. The highly preferred specialties (surgery, paediatrics, obstetrics and gynaecology, internal medicine) were those in which there was expectation of material rewards, societal appreciation, quick response of patients to treatment, and inspiration by teachers. The less preferred specialties were viewed negatively in these regards. The findings support the suggestion that, in order to give medical graduates a greater chance to see that the less preferred specialties can provide career fulfillment, interns should be allowed to spend part of their one year clinical rotation in radiology, pathology, psychiatry, anaesthesia and community medicine.

Apparent hypocalcaemia in Nigerian children with kwashiorkor

Thirty children with kwashiorkor had a mean +/- SEM plasma calcium (Ca) of 7.15 +/- 0.10mg/100ml; total proteins (TP) of 4.60 +/- 0.17g/100ml and albumin (A) of 1.89 +/- 0.11g/100ml. These values are significantly lower (p < 0.001) than the corresponding values of 9.07 +/- 0.10; 7.30 +/- 0.11 and 3.85 +/- 0.07 observed in thirty other age-matched normal controls. No significant differences exist in the plasma alkaline phosphatase (AP) levels in both groups. Correction of calcium for hypoalbuminaemia in the kwashiorkor group revealed that the observed hypocalcaemia in kwashiorkor is merely apparent.

HBsAg and aflatoxins in sera of rural (Igbo-Ora) and urban (Ibadan) populations in Nigeria

The purpose of this study was to screen for the presence of hepatitis B surface antigen and aflatoxins in the sera of 100 non-hospitalized individuals from the rural population of Igbo-Ora and 89 non-hospitalized individuals from the urban population of Ibadan, Nigeria. Hitherto, such a study as this has not been undertaken in this environment. The proportions of hepatitis B surface antigen carriage and serum 'pathologic' levels of aflatoxins were high (47-49%, 8.2-9.0% respectively) but varied very little between the two different populations sampled. These findings indicate that determined efforts should be instituted to reduce or eliminate hepatitis B virus infection and aflatoxin contamination of high risk foodstuffs from this environment.

The specialty choice of interns at Ibadan general hospitals

This cross-sectional study of house-officers at the two general hospitals in Ibadan is aimed at highlighting their preference for specialties, its evolution in the course of training, and its association with demographic variables. Fifty-one interns, consisting of 38 males and 13 females, and representing 84% response rate, participated. While at the time of study 48 (94%) had indicated a definite specialty choice, 45 (95.7%) of this group preferred surgery, internal medicine, paediatrics, or obstetrics and gynaecology. Radiology, community medicine, and anaesthesia were not even considered. Surgery was the most popular specialty. Specialty choice, evident before entry into university in 43% of the group, evolved during the course of training, being affected mainly by interest aroused during the clinical postings and the need for self-fulfillment. Specialty choice tended to fluctuate over the years. The findings are similar to those of clinical year students, and call for a consideration of the idea of interns rotating through the less favoured specialties.

The specialty choice of clinical year students at the Ibadan Medical School

This is a cross-sectional study of first and final year clinical students of the University of Ibadan, aimed at highlighting the students' preference for specialties, its evolution in the course of training and its correlation with demographic variables. One hundred and twenty-one first year clinical and 150 final year students participated, representing 81% and 89% response rates, respectively. Whereas at the time of study 92.9% of the students intended to specialise, over 81% of this group opted for surgery, internal medicine, paediatrics, obstetrics and gynaecology and general practice. Only 5.5% of the cohort chose radiology, psychiatry, community medicine, anaesthesia and pathology. Surgery was the most popular specialty. No socio-demographic factors seemed associated with specialty choice. Specialty choice, evident before entry into the University in 42.9% of the cohort, evolved during the course of training, being affected mainly by interest aroused during the postings and the need for self-fulfilment. Specialty choice tended to fluctuate over the years. Innovativeness and dedication on the part of teachers can arouse the interest of students during posting, so that specialty choice can be more evenly spread to meet national health manpower needs.

Beliefs and attitudes of clinical year students concerning medical specialties: an Ibadan medical school study

In order to understand their attitudes to 10 medical specialties, a 40-item self-report questionnaire was administered to the first and final year clinical students of the University of Ibadan. One hundred and twenty-one first year and 150 final year students participated, constituting 81% response rates respectively, in the two classes. The findings indicate that many factors influence specialty choice, the principal ones being: expectation of material rewards; societal appreciation of specialty and specialists; response of specialty patients to treatment; and the role of specialty teachers. It seems that specialties viewed positively in these dimentions (such as surgery, paediatrics, internal medicine, and obstetrics and gynaecology) are more highly favoured than the others (such as radiology, pathology, psychiatry, anaesthesia and community medicine), which were viewed rather negatively in this regard. Generally speaking, opinion on specialties was similar, not only between the two classes, but also between this cohort and comparable groups in developed nations. In order to enhance the spread of specialty manpower development to meet the goal of health care for all, suggestions are made about how to improve the positive appreciation of the less favoured specialties among undergraduates.

Duodenal intubation and aspiration test: utility in the differential diagnosis of infantile cholestasis

A prospective study involving 27 infants with cholestatic jaundice was carried out to evaluate the diagnostic utility of the 24-h duodenal drainage test. Extrahepatic cholestasis was confirmed by either exploratory laparotomy or autopsy in 12 of 13 cases without bile drainage, with only one false-positive result. The sensitivity of this test for extrahepatic cholestasis was 100% while the accuracy and specificity were 96.3 and 93.3%, respectively. The corresponding sensitivity, accuracy, and specificity for liver biopsy in patients with extrahepatic cholestasis were 83.3, 92.6, and 100%, respectively. It is concluded that the duodenal drainage test is a simple, rapid, and inexpensive procedure with high sensitivity and specificity in the diagnosis of infantile cholestasis.

Prothrombin time as an index of mortality in kwashiorkor

Prothrombin time, serum albumin, aminotransferases and liver size were evaluated in 40 consecutive cases of kwashiorkor. Eleven (27.5%) of the 40 patients died. Eight out of the 11 patients who died had a prolonged prothrombin time of more than 3 s above the control compared to only 4 out of the 29 who survived (p = 0.005). Mean serum aspartate aminotransferase (AST), alanine aminotransferase (ALT) albumin, globulin and liver size were abnormal but similar in both groups. These results may indicate a predictive mortality value of prothrombin time in kwashiorkor.

Acetylator status of kwashiorkor children in Ibadan (south-west Nigeria)

Acetylator status was determined in 25 kwashiorkor children, aged between 8 months and 3 years and in 25 age-matched control group of healthy children after a single oral dose of sulphamethazine (40 mg/kg body weight) and by measuring the acetylated sulphamethazine in blood samples, collected 6 h after the administration of sulphamethazine. The percentage of slow acetylators among kwashiorkor children was 40% while among the control group of children it was 48%. The difference between the two groups was not significant. Therefore, it is probable that the slow acetylator status of the Nigerian African children may not be a contributing factor for the development of kwashiorkor, a syndrome of protein-energy malnutrition. Furthermore, the polymorphic activity of N-acetyl transferase enzyme may not be impaired in kwashiorkor.