Innovative approaches to neonatal jaundice diagnosis and management in low-resourced settings

Persistent challenges in addressing severe neonatal hyperbilirubinaemia in resource-constrained settings have led to ongoing and often unacceptable rates of morbidity, disability and mortality. These challenges stem from limitations such as inadequate, inefficient or financially inaccessible diagnostic and therapeutic options. However, over the past decade, noteworthy innovations have emerged to address some of these hurdles, and these innovations are increasingly poised for broader implementation. This review provides a concise summary of these novel, economically viable diagnostic solutions, encompassing point-of-care assays and smartphone applications, as well as treatment modalities, notably more effective phototherapy and filtered sunlight. These advancements hold promise and have the potential to meaningfully reduce the burden of neonatal hyperbilirubinaemia, signifying a promising shift in the landscape of neonatal healthcare.

Maximizing Access and Minimizing Barriers to Research in Low- and Middle-Income Countries: Open Access and Health Equity

Access to published research has always been difficult for researchers and clinicians in low- and middle-income countries, because of the cost of and lack of access to the relevant publications. The dramatic recent increase in electronic research publications has resulted in a marked improvement in reader access to these publications through their mainly Open Access policies, however the costs of processing of submissions and publication have now become the burden of the researchers wishing to publish, rather than the readers. For many researchers working in LMIC, the Article Processing Charges (APC) are prohibitive, hampering the publication of research being conducted in and relevant to these countries. A number of grant funding agencies and international not-for-profit organizations are trying to address these issues by including funding for article publications in their grants, or by supporting publishing entities by subsiding the cost of publication, but more needs to be done by major journal publishers through markedly reducing the APC being charged to researchers in LMIC for open access facilities.

Clinical and growth outcomes of severely malnourished children following hospital discharge in a South African setting

Background

Data on outcomes of children with severe acute malnutrition (SAM) following treatment are scarce with none described from any upper-middle-income country. This study established mortality, clinical outcomes and anthropometric recovery of children with SAM six months following hospital discharge.

Methods

A prospective cohort study was conducted in children aged 3–59 months enrolled on discharge from two hospitals in the Tshwane district of South Africa between April 2019 and January 2020. The primary outcome was mortality at six months. Secondary outcomes included relapse rates, type(s) and frequency of morbidities experienced and the anthropometric changes in children with SAM following hospital discharge. Standard programmatic support included nutritional supplements.

Results

Forty-three children were enrolled with 86% of participants followed up to six months. Only a third of the participants had normal anthropometry at hospital discharge–a quarter still had ongoing SAM. There were no deaths, although four children (9%) were re-hospitalised including two for complicated SAM. Mean weight-for-length z-scores (WLZ) and wasting rates improved at one month but deteriorated by three months. At three months, six children (14%) either had ongoing or relapsed SAM–a SAM incidence rate of 20 per 1000 person-months despite more than half of the participants still receiving nutritional supplements at the time. Risk factors associated with persistent malnutrition at three months included a low WLZ on admission (relative risk [RR] 3.3, 95% confidence interval [95%CI] 1.2–9.2), being discharged from hospital before meeting WHO SAM treatment discharge criteria (RR 5.3, 95%CI 1.3–14.8) or having any illness by three months (RR 8.6, 95%CI 1.3–55.7).

Conclusion

Post-discharge mortality and morbidity was lower than in other less resourced settings. However, anthropometric recovery was poorer than expected. Modifying discharge criteria, optimising the use of available nutritional supplements and better integration with community-based health and social services may improve outcomes for children with SAM post-hospitalisation.

Epidemiology of SARS-CoV-2 infection and SARS-CoV-2 positive hospital admissions among children in South Africa

Introduction

We describe epidemiology and outcomes of confirmed SARS‐CoV‐2 infection and positive admissions among children <18 years in South Africa, an upper‐middle income setting with high inequality.

Methods

Laboratory and hospital COVID‐19 surveillance data, 28 January ‐ 19 September 2020 was used. Testing rates were calculated as number of tested for SARS‐CoV‐2 divided by population at risk; test positivity rates were calculated as positive tests divided by total number of tests. In‐hospital case fatality ratio (CFR) was calculated based on hospitalized positive admissions with outcome data who died in‐hospital and whose death was judged SARS‐CoV‐2 related by attending physician.

Findings

315 570 children aged <18 years were tested for SARS‐CoV‐2; representing 8.9% of all 3 548 738 tests and 1.6% of all children in the country. Of children tested, 46 137 (14.6%) were positive. Children made up 2.9% (n = 2007) of all SARS‐CoV‐2 positive admissions to sentinel hospitals. Among children, 47 died (2.6% case‐fatality). In‐hospital deaths were associated with male sex [adjusted odds ratio (aOR) 2.18 (95% confidence intervals [CI] 1.08–4.40)] vs female; age <1 year [aOR 4.11 (95% CI 1.08–15.54)], age 10–14 years [aOR 4.20 (95% CI1.07–16.44)], age 15–17 years [aOR 4.86 (95% 1.28–18.51)] vs age 1–4 years; admission to a public hospital [aOR 5.07(95% 2.01–12.76)] vs private hospital and ≥1 underlying conditions [aOR 12.09 (95% CI 4.19–34.89)] vs none.

Conclusions

Children with underlying conditions were at greater risk of severe SARS‐CoV‐2 outcomes. Children > 10 years, those in certain provinces and those with underlying conditions should be considered for increased testing and vaccination.

Health system factors affecting implementation of integrated management of childhood illness (IMCI): qualitative insights from a South African province

The Integrated Management of Childhood Illness (IMCI) strategy has been adopted by 102 countries including South Africa, as the preferred primary health care (PHC) delivery strategy for sick children under 5 years. Despite substantial investment to support IMCI in South Africa, its delivery remains sub-optimal, with varied implementation in different settings. There is scarce research globally, and in the local context, examining the effects of health system characteristics on IMCI implementation. This study explored key determinants of IMCI delivery in a South African province, with a specific focus on health system building blocks using a health system dynamics framework. In-depth interviews were conducted with 38 districts, provincial and national respondents involved with IMCI co-ordination and delivery, exploring their involvement in, and perceptions of, IMCI strategy implementation. Identified barriers included poor definition of elements of a service package for children and how IMCI aligned with this, incompetence of trained nurses exacerbated by inappropriate rotation practices, use of inappropriate indicators to track progress, multiple cadres coordinating similar activities with poor role delineation, and fragmented, vertical governance of programmes included within IMCI, such as immunization. Enabling practices in one district included the use of standardized child health records incorporating IMCI activities and stringent practice monitoring through record audits. Using IMCI as a case study, our work highlights critical health system deficiencies affecting service delivery for young children which need to be resolved to reposition IMCI within the broader child 'survive, thrive and transform' agenda. Recommendations for appropriate health system strengthening include the need for redefining IMCI within a broader PHC service package for children, prioritizing post-training supervision and mentoring of practitioners through appropriate duty allocation and rotation policies, strengthening IMCI monitoring with a specific focus on quality of care and building stronger clinical governance through workforce allocation, role delineation and improved accountability.

Comparison of nuisance parameters in pediatric versus adult randomized trials: a meta-epidemiologic empirical evaluation

Background

We wished to compare the nuisance parameters of pediatric vs. adult randomized-trials (RCTs) and determine if the latter can be used in sample size computations of the former.

Methods

In this meta-epidemiologic empirical evaluation we examined meta-analyses from the Cochrane Database of Systematic-Reviews, with at least one pediatric-RCT and at least one adult-RCT. Within each meta-analysis of binary efficacy-outcomes, we calculated the pooled-control-group event-rate (CER) across separately all pediatric and adult-trials, using random-effect models and subsequently calculated the control-group event-rate risk-ratio (CER-RR) of the pooled-pediatric-CERs vs. adult-CERs. Within each meta-analysis with continuous outcomes we calculated the pooled-control-group effect standard deviation (CE-SD) across separately all pediatric and adult-trials and subsequently calculated the CE-SD-ratio of the pooled-pediatric-CE-SDs vs. adult-CE-SDs. We then calculated across all meta-analyses the pooled-CER-RRs and pooled-CE-SD-ratios (primary endpoints) and the pooled-magnitude of effect-sizes of CER-RRs and CE-SD-ratios using REMs. A ratio < 1 indicates that pediatric trials have smaller nuisance parameters than adult trials.

Results

We analyzed 208 meta-analyses (135 for binary-outcomes, 73 for continuous-outcomes). For binary outcomes, pediatric-RCTs had on average 10% smaller CERs than adult-RCTs (summary-CE-RR: 0.90; 95% CI: 0.83, 0.98). For mortality outcomes the summary-CE-RR was 0.48 (95% CIs: 0.31, 0.74). For continuous outcomes, pediatric-RCTs had on average 26% smaller CE-SDs than adult-RCTs (summary-CE-SD-ratio: 0.74).

Conclusions

Clinically relevant differences in nuisance parameters between pediatric and adult trials were detected. These differences have implications for design of future studies. Extrapolation of nuisance parameters for sample-sizes calculations from adult-trials to pediatric-trials should be cautiously done.

Child Sexual Abuse in Zimbabwe

Although child sexual abuse is a significant public health problem globally, its incidence, prevention, and management is less well described in resource-poor settings. In poorer settings prevention initiatives assume even more importance since resources for managing abused children are severely limited. This article examines the current status of policy and practice related to the prevention of child sexual abuse in Zimbabwe. It identifies implementation challenges and highlights opportunities that could be embraced to reduce CSA in Zimbabwe, based on evidence synthesized from recent work. Although Zimbabwe has a well-established legal and regulatory framework to protect children from child sexual abuse, implementation of existing policies is weak. Financial, human, and material resource constraints are frequently cited to explain limited prevention activity. Effective strategies for the prevention of child sexual abuse should focus on implementing existing legislation, targeting schoolchildren, and getting community involvement. A dedicated budget would help entrench these strategies, but gains can be achieved even in the absence of this.

Maternal risk exposure during pregnancy and infant birth weight

BACKGROUND

Birth weight is an important determinant of an infant's immediate and future health.

AIM

This study examined associations between selected maternal psychosocial and environmental risk factors during pregnancy and subsequent infant birth weight, utilising data from the South African Birth to Twenty Plus (Bt20+) birth cohort study.

SUBJECTS

Exposure to nine maternal risks were assessed in 1228 women who completed an antenatal questionnaire and whose infants were delivered within a seven-week period.

OUTCOME MEASURES

The outcome of interest was infant birth weight. Birth weight z-scores (BWZ) were calculated using the World Health Organization Child Growth Standards. Bivariate analyses and multiple regression models were used to identify significant risk factors.

RESULTS

The mean infant birth weight was 3139g (SD 486g), with a significant advantage in mean birth weight for male infants of 73g (p=0.008). Being unsure or not wanting the pregnancy was associated with a ~156g reduction in infant birth weight (β=-0.32; 95% CI -0.51; -0.14). Tobacco use during pregnancy was also negatively associated with BWZ (β=-0.32; 95% CI -0.59; -0.05). Exposure to both significant risk factors (tobacco use and pregnancy wantedness) was associated with cumulative reductions in birth weight, particularly among boys.

CONCLUSIONS

This study reinforces the importance of risks related to maternal attitudes and behaviours during pregnancy, namely unwanted pregnancy and tobacco use, which significantly lowered birth weight. Both identified risks are amenable to public health policy and programme intervention.

Anti-inflammatory treatment for carditis in acute rheumatic fever

BACKGROUND

Rheumatic heart disease remains an important cause of acquired heart disease in developing countries. Although prevention of rheumatic fever and management of recurrences have been well established, optimal management of active rheumatic carditis remains unclear. This is an update of a review published in 2003, and previously updated in 2009 and 2012.

OBJECTIVES

To assess the effects, both harmful and beneficial, of anti-inflammatory agents such as aspirin, corticosteroids and other drugs in preventing or reducing further valvular damage in patients with acute rheumatic fever.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (2013, Issue 9 of 12), MEDLINE (Ovid, 1948 to 2013 October Week 1), EMBASE (Ovid, 1980 to 2013 Week 41) and Latin American Caribbean Health Sciences Literature (LILACS) (1982 to 17 October 2013). We last searched Index Medicus (1950 to April 2001) in 2001. We checked reference lists of identified studies and applied no language restrictions.

SELECTION CRITERIA

Randomised controlled trials comparing anti-inflammatory agents (e.g. aspirin, steroids, immunoglobulins, pentoxifylline) versus placebo or controls, or comparing any of the anti-inflammatory agents versus one another, in adults and children with acute rheumatic fever diagnosed according to Jones, or modified Jones, criteria. The presence of cardiac disease one year after treatment was the major outcome criterion selected.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed risk of bias using the methodology outlined in the Cochrane Handbook of Systematic Reviews of Interventions. Standard methodological procedures as expected by The Cochrane Collaboration were used.

MAIN RESULTS

No new studies were included in this update. Eight randomised controlled trials involving 996 people were selected for inclusion in the review. Researchers compared several steroidal agents such as corticotrophin, cortisone, hydrocortisone, dexamethasone, prednisone and intravenous immunoglobulin versus aspirin, placebo or no treatment. Six trials were conducted between 1950 and 1965; one was done in 1990 and the final study was published in 2001. Overall there were no observed significant differences in risk of cardiac disease at one year between corticosteroid-treated and aspirin-treated groups (six studies, 907 participants, risk ratio 0.87, 95% confidence interval 0.66 to 1.15). Similarly, use of prednisone (two studies, 212 participants, risk ratio 1.13, 95% confidence interval 0.52 to 2.45) compared with aspirin did not reduce the risk of heart disease after one year. Investigators in five studies did not report adverse events. The three studies reporting on adverse events reported substantial adverse events. However, all results should be interpreted with caution because of the age of the studies and the substantial risk of bias.

AUTHORS' CONCLUSIONS

Little evidence of benefit was found when corticosteroids or intravenous immunoglobulins were used to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. In addition, risk of bias was substantial, so results should be viewed with caution. New randomised controlled trials in patients with acute rheumatic fever are warranted to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisolone and the effects of other new anti-inflammatory agents. Advances in echocardiography will allow more objective and precise assessments of cardiac outcomes.

Anti-inflammatory treatment for carditis in acute rheumatic fever

BACKGROUND

Rheumatic heart disease remains an important cause of acquired heart disease in developing countries. Although the prevention of rheumatic fever and the management of recurrences is well established, the optimal management of active rheumatic carditis is still unclear. This is an update of a review published in 2003 and previously updated in 2009.

OBJECTIVES

To assess the effects of anti-inflammatory agents such as aspirin, corticosteroids, immunoglobulin and pentoxifylline for preventing or reducing further heart valve damage in patients with acute rheumatic fever.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2011), MEDLINE (1966 to Aug 2011), EMBASE (1998 to Sept 2011), LILACS (1982 to Sept 2011), Index Medicus (1950 to April 2001) and references lists of identified studies. No language restrictions were applied.

SELECTION CRITERIA

Randomised controlled trials comparing anti-inflammatory agents (e.g. aspirin, steroids, immunoglobulins, pentoxifylline) with placebo or controls, or comparing any of the anti-inflammatory agents with one another, in adults and children with acute rheumatic fever diagnosed according to the Jones, or modified Jones criteria. The presence of cardiac disease one year after treatment was the major outcome criteria selected.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data. Risk of bias was assessed using methodology outlined in the Cochrane handbook.

MAIN RESULTS

No new studies were included in this update. Eight randomised controlled trials involving 996 people were included. Several steroidal agents corticotrophin, cortisone, hydrocortisone, dexamethasone and prednisone, and intravenous immunoglobulin were compared to aspirin, placebo or no treatment in the various studies. Six of the trials were conducted between 1950 and 1965, one study was done in 1990, and the final study was published in 2001. Overall there was no significant difference in the risk of cardiac disease at one year between the corticosteroid-treated and aspirin-treated groups (six studies, 907 participants, relative risk 0.87, 95% confidence interval 0.66 to 1.15). Similarly, use of prednisone (two studies, 212 participants, relative risk 1.13, 95% confidence interval 0.52 to 2.45) compared to aspirin did not reduce the risk of developing heart disease after one year. Adverse events were not reported in five studies. The three studies reporting on adverse events all reported substantial adverse events. However, all results should be interpreted with caution due to the age of the studies and to substantial risk of bias.

AUTHORS' CONCLUSIONS

There is little evidence of benefit from using corticosteroids or intravenous immunoglobulins to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. Additionally there was substantial risk of bias, so results should be viewed with caution. New randomised controlled trials in patients with acute rheumatic fever to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisolone, and other new anti-inflammatory agents are warranted. Advances in echocardiography will allow for more objective and precise assessments of cardiac outcomes.

HIV and infant feeding – one step forward, two steps back

The recent decision by the South African Health Department to withdraw the provision of free replacement (formula) feeds to HIV-exposed infants has hardly evoked any response from clinicians, health professionals or civil society groups. This paper argues that the decision is short-sighted, lacks an adequate evidence base, and is retrogressive and unconstitutional. Nine supporting arguments are presented and an alternative policy proposed.

Clinical outcomes of severe malnutrition in a high tuberculosis and HIV setting

OBJECTIVE

Case death rates for severe childhood malnutrition remain stubbornly elevated in high HIV prevalence settings, despite the implementation of WHO guidelines. This study examined case death and other clinical outcomes in malnourished children with and without HIV infection.

METHODS

A prospective, observational study was undertaken at three tertiary hospitals in Johannesburg, South Africa. All severely malnourished children had their HIV status established, and anthropometric, clinical and diagnostic findings and admission outcomes were analysed.

FINDINGS

Just over half (51%) of the 113 severely malnourished children were HIV infected, but 31/58 (54%) of these children had their positive status diagnosed only after admission. Marasmic children were significantly more likely to be HIV infected (OR 9.7, 95% CI 3.5 to 29.1). Tuberculosis (TB) was strongly suspected and treated in 27 children (24%) although confirmed in only five (4%). The overall case death rate was 11.5%. HIV infection, pallor and shock were significant predictors of death. HIV-infected children were six times more likely to die compared with HIV-negative children (19% vs 3.6%, OR 6.2, 95% CI 1.2 to 59). HIV-'affected' children (HIV negative but exposed) and HIV-negative children had similar outcomes.

CONCLUSION

HIV infection significantly increases severe malnutrition case death. WHO guidelines for the management of severe malnutrition in high HIV prevalence settings need to be modified to include routine HIV and TB testing and offer guidance on the criteria and timing of TB treatment and highly active antiretroviral therapy initiation.

Feeding of infants of HIV-positive mothers

PURPOSE OF REVIEW

To highlight recent research that has contributed to an improved understanding of, or resulted in, important changes in the approach to feeding HIV-exposed infants.

RECENT FINDINGS

The administration of antiretroviral therapy to a HIV-positive pregnant woman and its continued use during breast-feeding significantly reduce postnatal HIV transmission to her child. Similarly, extended antiretroviral prophylaxis to the breast-feeding infant dramatically decreases HIV transmission and promotes HIV-free child survival. Predominant breast-feeding may be as effective as exclusive breast-feeding in reducing HIV transmission risk. The protective role of immune modulators such as interferon-gamma and interleukin-15 in preventing breast milk transmission is being better appreciated. Although infant-feeding counseling is critical to the success of infant survival strategies, it is generally done poorly with few examples of successful consequences other than in research settings.

SUMMARY

Breast-feeding of HIV-exposed infants can be made considerably safer in resource-constrained settings through the provision of maternal highly active antiretroviral therapy (HAART), maternal short-course antiretrovirals, and extended infant antiretroviral prophylaxis.

Supplementary feeding with either ready-to-use fortified spread or corn-soy blend in wasted adults starting antiretroviral therapy in Malawi: randomised, investigator blinded, controlled trial

OBJECTIVE

To investigate the effect of two different food supplements on body mass index (BMI) in wasted Malawian adults with HIV who were starting antiretroviral therapy.

DESIGN

Randomised, investigator blinded, controlled trial.

SETTING

Large, public clinic associated with a referral hospital in Blantyre, Malawi.

PARTICIPANTS

491 adults with BMI <18.5.

INTERVENTIONS

Ready-to-use fortified spread (n=245) or corn-soy blend (n=246).

PRIMARY OUTCOMES

changes in BMI and fat-free body mass after 3.5 months.

SECONDARY OUTCOMES

survival, CD4 count, HIV viral load, quality of life, and adherence to antiretroviral therapy.

RESULTS

The mean BMI at enrolment was 16.5. After 14 weeks, patients receiving fortified spread had a greater increase in BMI and fat-free body mass than those receiving corn-soy blend: 2.2 (SD 1.9) v 1.7 (SD 1.6) (difference 0.5, 95% confidence interval 0.2 to 0.8), and 2.9 (SD 3.2) v 2.2 (SD 3.0) kg (difference 0.7 kg, 0.2 to 1.2 kg), respectively. The mortality rate was 27% for those receiving fortified spread and 26% for those receiving corn-soy blend. No significant differences in the CD4 count, HIV viral load, assessment of quality of life, or adherence to antiretroviral therapy were noted between the two groups.

CONCLUSION

Supplementary feeding with fortified spread resulted in a greater increase in BMI and lean body mass than feeding with corn-soy blend.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN67515515.

What's new? Investigating risk factors for severe childhood malnutrition in a high HIV prevalence South African setting

AIM

To identify risk factors for severe childhood malnutrition in a rural South African district with a high HIV/AIDS prevalence.

DESIGN

Case-control study.

SETTING

Bushbuckridge District, Limpopo Province, South Africa.

PARTICIPANTS

100 children with severe malnutrition (marasmus, kwashiorkor, and marasmic kwashiorkor) were compared with 200 better nourished (>-2 SD weight-for-age) controls, matched by age and village of residence. Bivariate and multivariate analyses were conducted on a variety of biological and social risk factors.

RESULTS

HIV status was known only for a minority of cases (39%), of whom 87% were HIV positive, while 45% of controls were stunted. In multivariate analysis, risk factors for severe malnutrition included suspicion of HIV in the family (parents or children) (OR 217.7, 95% CI 22.7-2091.3), poor weaning practices (OR 3.0, 95% CI 2.0-4.6), parental death (OR 38.0, 95% CI 3.8-385.3), male sex (OR 2.7, 95% CI 1.2-6.0), and higher birth order (third child or higher) (OR 2.3, 95% CI 1.0-5.1). Protective factors included a diverse food intake (OR 0.53, 95% CI 0.41-0.67) and receipt of a state child support grant (OR 0.44, 95% CI 0.20-0.97). A borderline association existed for family wealth (OR 0.9 per unit, 95% CI 0.83-1.0), father smoking marijuana (OR 3.9, 95% CI 1.1-14.5), and history of a pulmonary tuberculosis contact (OR 3.2, 95% CI 0.9-11.0).

CONCLUSIONS

Despite the increasing contribution of HIV to the development of severe malnutrition, traditional risk factors such as poor nutrition, parental disadvantage and illness, poverty, and social inequity remain important contributors to the prevalence of severe malnutrition. Interventions aiming to prevent and reduce severe childhood malnutrition in high HIV prevalence settings need to encompass the various dimensions of the disease: nutritional, economic, and social, and address the prevention and treatment of HIV/AIDS.

Unmet health, welfare and educational needs of disabled children in an impoverished South African peri-urban township

BACKGROUND

Childhood disability in South Africa has failed to receive adequate attention from governmental agencies, such as the health, education and social welfare departments, despite there being more than 1 million disabled children in the country. This study sought to assess the unmet rehabilitation, education and welfare needs of disabled children living in a peri-urban township.

METHODS

As no register of disabled children existed, snowball sampling was used to recruit a convenience sample of 156 disabled children living in Orange Farm township near Soweto, South Africa. Children's impairments, their health and educational needs, and the availability and utilization of services were assessed using a structured interview.

RESULTS

Few disabled children attended pre-school (35%) or school (44%). Only a quarter (26%) of children in need of rehabilitation received such services. Children with motor impairments were more likely to receive rehabilitation than those with intellectual impairment (44% vs. 8%, P < 0.0001). Of the 233 assistive devices required, only 64 (28%) had been issued. Less than half (45%) of the children entitled to a social assistance grant were receiving it. Lack of money, limited awareness about available services, and bureaucratic obstacles were the main reasons offered by caregivers for the low utilization of available services and resources.

CONCLUSION

Children with disabilities living in Orange Farm are not enjoying the rights and services to which they are entitled. Innovative, co-ordinated service delivery strategies, and better-informed caregivers combined with community recognition of, and support for, the needs of disabled children are required to address these unmet needs.

Earlier discharge of very low birthweight infants from an under-resourced African hospital: a randomised trial

BACKGROUND

Very low birthweight (VLBW) infants contribute substantially to the workload and expenditure of any neonatal unit. Earlier discharge might offer advantages to the infant, the family and the health service.

AIM

To establish the outcome of preterm, VLBW infants discharged at a weight of > or = 1650 g compared with the unit's practise of discharging at a weight of > or = 1800 g.

METHODS

A total of 120 infants (62 early discharges, 58 routine discharges) were followed up for 3 months after discharge from Chris Hani Baragwanath Hospital in Soweto, South Africa. The early-discharge group was discharged at > or = 1650 g and the routine-discharge group at > or = 1800 g. Growth, morbidity and mortality at 1 and 3 months after discharge were compared.

RESULTS

At 3 months, the rate of weight gain (mean 30 vs 33 g/kg/day, p=0.06) and head circumference growth (38.9 vs 39.5 cm, p=0.10) were similar in both groups. There were no differences between the early- and routine-discharge groups in the number of outpatient visits (24 vs 16, p=0.18), frequency of re-admission (9 vs 4, p=0.17) or mortality [1 (1.6%) vs 3 (5.2%), p=0.27] following discharge.

CONCLUSION

If home circumstances are adequate, it is as safe to discharge well, singleton VLBW infants from hospital at a weight of > or = 1650 g as at > or = 1800 g.

Prophylactic versus selective antibiotics for term newborn infants of mothers with risk factors for neonatal infection

BACKGROUND

Early onset bacterial infection is an important cause of morbidity and mortality in newborn infants. Various factors that increase the risk of neonatal infection have been identified. It is unclear whether asymptomatic newborn infants born to mothers with one or more of these risk factors should receive antibiotics prophylactically rather than selectively if only clinical or microbiological evidence of sepsis emerges.

OBJECTIVES

To assess the effect of prophylactic versus selective antibiotic treatment for asymptomatic term neonates born to mothers with risk factors for neonatal infection.

SEARCH STRATEGY

We used the standard methods of the Cochrane Neonatal Review Group. We searched MEDLINE (1966 - May 2004), EMBASE (1980 - May 2004), LILACS (1982 - 2003), SciELO (1997 - 2003), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2004), and Centers for Disease Control and Prevention protocols and guidelines on the subject.

SELECTION CRITERIA

Randomized controlled trials, or trials using quasi-random methods of allocation, comparing the use of prophylactic versus selective antibiotics in asymptomatic neonates born to mothers with one or more risk factors for infection.

DATA COLLECTION AND ANALYSIS

We extracted the data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by three reviewers and synthesis of data using relative risk and risk difference. The pre-specified primary outcomes were neonatal mortality, systemic neonatal infection, and need for admission to a neonatal intensive care unit.

MAIN RESULTS

We identified two small trials undertaken in the 1970s. Both trials had methodological weaknesses. There was no evidence of an effect on any of the primary outcomes, but because the trials were underpowered, clinically important effect sizes may have been missed.

REVIEWERS' CONCLUSIONS

There are insufficient data from randomized controlled trials to guide clinical practice. A large randomized controlled trial is needed in asymptomatic term infants born to mothers with risk factors for infection in their babies, which compares the effect of prophylactic versus selective antibiotics on morbidity, mortality and costs.

The prevention and management of congenital syphilis: an overview and recommendations

The continued occurrence of congenital syphilis is an indictment of the inadequate antenatal care services and poor quality of programmes to control sexually transmitted infections. More than 1 million infants are born with congenital syphilis each year. Despite national policies on antenatal testing and the widespread use of antenatal services, syphilis screening is still implemented only sporadically in many countries, leaving the disease undetected and untreated among many pregnant women. The weak organization of services and the costs of screening are the principal obstacles facing programmes. Decentralization of antenatal syphilis screening programmes, on-site testing and immediate treatment can reduce the number of cases of congenital syphilis. Antenatal syphilis screening and treatment programmes are as cost effective as many existing public health programmes, e.g. measles immunization. Diagnosis of congenital syphilis is problematic since more than half of all infants are asymptomatic, and signs in symptomatic infants may be subtle and nonspecific. Newer diagnostic tests such as enzyme immunoassays, polymerase chain reaction and immunoblotting have made diagnosis more sensitive and specific but are largely unavailable in the settings where they are most needed. Guidelines developed for better-resourced settings are conservative and err on the side of overtreatment. They are difficult to implement in, or inappropriate for, poorly-resourced settings because of the lack of investigative ability and the pressure on health facilities to discharge infants early. This paper offers recommendations for treating infants, including an approach based solely on maternal serological status and clinical signs of syphilis in the infant.

Anti-inflammatory treatment for carditis in acute rheumatic fever

BACKGROUND

Rheumatic heart disease remains the most important cause of acquired heart disease in developing countries. Although the prevention of rheumatic fever and the management of recurrences is well established the optimal management of active rheumatic carditis is still unclear.

OBJECTIVES

To assess the effects of anti-inflammatory agents such as aspirin, corticosteroids and immunoglobulin for preventing or reducing further heart valve damage in patients with acute rheumatic fever.

SEARCH STRATEGY

We searched the Cochrane Controlled Trials Register (Issue 4, 2000), MEDLINE (1966 to April 2002), EMBASE (1998 to November 2002), LILACS (1998 to November 2002), Index Medicus (1950 to December 2000) and references lists of identified studies.

SELECTION CRITERIA

Randomised controlled trials comparing anti-inflammatory agents (e.g. aspirin, steroids, immunoglobulins) with placebo or controls, or comparing any of the anti-inflammatory agents with one another, in patients with acute rheumatic fever diagnosed according to the Jones, or modified Jones criteria. The presence of cardiac disease one year after treatment was the major outcome criteria selected.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed trial quality.

MAIN RESULTS

Eight randomised controlled trials involving 996 people were included. Several steroidal agents viz. ACTH, cortisone, hydrocortisone, dexamethasone and prednisone, and intravenous immunoglobulin were compared to aspirin, placebo or no treatment in the various studies. Six of the trials were conducted between 1950 and 1965, whilst the remaining two were done in the last 10 years. Overall there was no significant difference in the risk of cardiac disease at one year between the corticosteroid-treated and aspirin-treated groups (relative risk 0.87, 95% confidence interval 0.66 to 1.15). Similarly use of prednisone (relative risk 1.78, 95% confidence interval 0.98 to 3.34) or intravenous immunoglobulins (relative risk 0.87, 95%confidence interval 0.55 to 1.39) when compared to placebo did not reduce the risk of developing heart valve lesions at one year.

REVIEWER'S CONCLUSIONS

There is no benefit in using corticosteroids or intravenous immunoglobulins to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. New randomised controlled trials in patients with acute rheumatic fever to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisone, and other new anti-inflammatory agents are warranted. Advances in echocardiography will allow for more objective and precise assessment of cardiac outcomes.

Implementation of WHO guidelines on management of severe malnutrition in hospitals in Africa

OBJECTIVE

To investigate the problems, benefits, feasibility, and sustainability of implementation of WHO guidelines on management of severe malnutrition.

METHODS

A postal survey invited staff from 12 African hospitals to participate in the study. Five hospitals were evaluated and two were selected to take part in the study: a district hospital in South Africa and a mission hospital in Ghana. At an initial visit, an experienced paediatrician reviewed the situation in the hospitals and introduced the principles of the guidelines through a participatory approach. During a second visit about six months later, the paediatrician reviewed the feasibility and sustainability of the introduced changes and helped find solutions to problems. At a final visit after one year, the paediatrician reassessed the overall situation.

FINDINGS

Malnutrition management practices improved at both hospitals. Measures against hypoglycaemia, hypothermia, and infection were strengthened. Early, frequent feeding was established as a routine practice. Some micronutrients for inclusion in the diet were not locally available and needed to be imported. Problems were encountered with monitoring of weight gain and introducing a rehydration solution for malnutrition.

CONCLUSION

Implementation of the main principles of the WHO guidelines on severe malnutrition was feasible, affordable, and sustainable at two African hospitals. The guidelines could be improved by including suggestions on how to adapt specific recommendations to local situations. The guidelines are well supported by experience and published reports, but more information is needed about some components and their impact on mortality.

Lower respiratory tract infections associated with influenza A and B viruses in an area with a high prevalence of pediatric human immunodeficiency type 1 infection

BACKGROUND

Despite the high burden of pediatric HIV-1 infection in developing countries, there are few data on the clinical course of influenza virus-associated lower respiratory tract infection (LRTI) in these children.

OBJECTIVE

To define and compare the clinical course of HIV-1-infected and -uninfected African children hospitalized with influenza virus associated severe LRTI.

METHODS

Children with severe LRTI were prospectively recruited between March, 1997, and March, 1999, as part of a broader study evaluating the etiology and outcome of this condition in hospitalized HIV-1-infected and -uninfected children. The results of children in whom influenza A or B virus was identified by immunofluorescent antibody staining after shell vial culture are reported. Viruses isolated were typed by hemagglutination inhibition assays.

RESULTS

Twenty-five (21.6%) of the 116 children hospitalized with severe LRTI in whom influenza A or B virus was identified were HIV-1-infected. HIV-1-infected children were older than uninfected children (mean age +/- SD 17.4 +/- 10.8 months vs. 10.2 +/- 8.9 months; P = 0.002). HIV-1-infected children were more likely to have an underlying medical illness (in addition to HIV-1 infection) predisposing them to more severe LRTI (32.0% vs. 13.2%; P = 0.03). HIV-infected children were also more likely to have indirect evidence of bacterial coinfection, including chest radiographic evidence of confluent alveolar consolidation (78.9% vs. 35.1%, P = 0.006), and were less likely be wheezing (8.0% vs. 31.9%, P = 0.01). However, there was no difference in the clinical outcome of HIV-1-infected and -uninfected children. The duration of hospitalization [median (range) 5 (2 to 33) days vs. 4 (0 to 21) days, P = 0.08] and the mortality rates (8.0% vs. 2.2%, P = 0.20) were similar between HWV-1-infected and -uninfected children.

CONCLUSION

HIV-1-infected children hospitalized with severe LRTI associated with influenza virus have an outcome similar to that of HIV-1-uninfected children even in the absence of antiretroviral or anti-influenza virus treatment.

Reduced effectiveness of Haemophilus influenzae type b conjugate vaccine in children with a high prevalence of human immunodeficiency virus type 1 infection

BACKGROUND

Haemophilus influenzae type b (Hib) conjugate vaccines have successfully reduced the burden of invasive Hib disease in developed countries; however, their effectiveness in countries with a high incidence of pediatric HIV-1 is unknown.

METHODS

The effectiveness of Hib conjugate vaccine was prospectively evaluated in South African children. The burden of invasive Hib disease in children < 1 year old was compared in 2 cohorts. The first cohort included 22,000 African children born in 1997 [969 (4.45%) of whom were estimated to be HIV-1-infected] who were not vaccinated with Hib conjugate vaccine. This group was compared with 19,267 children [1162 (6.03%) of whom were estimated to be HIV-1 infected] vaccinated at 6, 10 and 14 weeks of age with an Hib conjugate vaccine [TETRAMUNE (polyribosylribitol phosphate-CRM(197)-diphtheria-tetanus toxoids-whole cell pertussis)] between March, 1998, and June, 1999.

RESULTS

The estimated burden of invasive Hib disease in nonimmunized HIV-1-infected children < 1 year of age was 5.9-fold [95% confidence interval (95% CI), 2.7 to 12.6] higher than in HIV-1-uninfected children. The overall estimated effectiveness of Hib conjugate vaccine in fully vaccinated children <1 year of age was 83.2% (95% CI 60.3 to 92.9). Vaccine effectiveness was significantly reduced in HIV-1-infected [43.9% (95% CI -76.1 to 82.1)] compared with uninfected children [96.5% (95% CI 74.4 to 99.5); P < 10(-5)]. Among three of the fully vaccinated HIV-1-infected children who developed invasive Hib disease, the anti-Hib polyribosylribitol phosphate serum antibody concentrations were 0.23, 0.25 and 0.68 microg/ml.

CONCLUSION

Although the Hib conjugate vaccine was less effective among HIV-1-infected than among uninfected children, it was 83% effective in preventing overall invasive Hib disease and therefore should be considered for inclusion in the routine vaccination schedule by other African countries.

The health professional's role in preventing nosocomial infections

Despite their best intentions, health professionals sometimes act as vectors of disease, disseminating new infections among their unsuspecting clients. Attention to simple preventive strategies may significantly reduce disease transmission rates. Frequent hand washing remains the single most important intervention in infection control. However, identifying mechanisms to ensure compliance by health professionals remains a perplexing problem. Gloves, gowns, and masks have a role in preventing infections, but are often used inappropriately, increasing service costs unnecessarily. While virulent microorganisms can be cultured from stethoscopes and white coats, their role in disease transmission remains undefined. There is greater consensus about sterile insertion techniques for intravascular catheters-a common source of infections-and their care. By following a few simple rules identified in this review, health professionals may prevent much unnecessary medical and financial distress to their patients.

Survival of low-birth-weight infants at Baragwanath Hospital--1950-1996

OBJECTIVES

To examine changes in survival rates among low-birth-weight (LBW) infants between the years 1950 and 1996.

METHODS

Survival figures were analysed for LBW infants managed at Baragwanath Hospital, a tertiary care centre in Soweto, Johannesburg, over four periods spanning five decades.

RESULTS

The overall mortality rates of LBW infants decreased markedly between the early 1950s and the period 1995/96. By the mid-1990's approximately four times the number of infants with birth weight less than 1,500 g were surviving compared with the early 1950s. The reduction in mortality rates occurred in all LBW groups during the first three decades. However, since 1981 infants who weighed less than 1,500 g at birth were the major contributors to the overall reduction in mortality. Between the years 1981/82 and 1995/96, survival increased significantly from 64% to 79% for infants with birth weight 1,000-1,499 g, and from 14% to 32% for those with birth weight less than 1,000 g. Since infants in the latter group were seldom offered mechanical ventilation or artificial surfactant, a large part of these increases in survival can be attributed to improvement in the general level of care.

CONCLUSION

There have been dramatic improvements in the survival of LBW infants over this time period at Baragwanath Hospital. Although newer interventions such as mechanical ventilation and artificial surfactant have played a significant role, improvement in care at primary and secondary levels has been of major importance.

Is registrarship a different experience for women?

OBJECTIVE

To determine differences between male and female registrars in their subjective perceptions and experience of a paediatrics registrar training programme.

DESIGN

Cross-sectional survey.

SETTING

University-affiliated teaching hospitals.

PARTICIPANTS

Thirty-nine paediatrics registrars.

RESULTS

Of the 39 respondents, 18 (46%) were women. Men were older than women (30.4 v. 29.1 years, P = 0.049). There were no gender differences in the number of hours worked per week (65.7 v. 67.8 hours, P = 0.384) or participation in the training programme. Success rates in postgraduate paediatrics examinations were also similar for the two groups (85% v. 76% P = 0.486). Male registrars were more likely to have 'moonlighted' (43% v. 6%, P = 0.011). Fifty-nine per cent of female registrars believed that they had been disadvantaged in their careers because of their gender, 28% felt that more was expected of a woman registrar and 22% of the female trainees claimed to have been subjected to sexual harassment. The majority (82%) of women registrars contemplated taking time off from practising clinical paediatrics in the future (post-registrarship), mainly for child-bearing purposes. Female respondents criticised both the academic department and the hospital authorities for discriminatory practices, such as the awarding of home loans to men and women who were breadwinners only. The findings suggest that women registrars do feel disadvantaged and discriminated against, and highlight the need for flexible, creative programmes that recognise the needs and aspirations of female registrars and, indeed, all women in academic medicine.