South African Journal of Child Health - Volume 3, Issue 1, 2009
Volume 3, Issue 1, 2009
Author Nonhlanhla P. KhumaloSource: South African Journal of Child Health 3 (2009)More Less
This issue of SAJCH starts with a contribution to our 'Hot Topics' section by John Frean, who calls for 'no grounds for complacency' in spite of the relatively low malaria disease burden in South Africa. He gives a comprehensive summary of achievements to date, including new drugs and vector control, but also highlights challenges.
Author John FreanSource: South African Journal of Child Health 3 (2009)More Less
Compared with most of sub-Saharan Africa, South Africa is fortunate in several ways regarding malaria: it is at the southern extreme of malaria distribution on the continent, and relatively small areas experience seasonal transmission; it has a well-organised national malaria control programme; and it has a relatively well-developed scientific, economic and health infrastructure. However, problems with importation of malaria cases from neighbouring countries, antimalarial drug resistance, vector insecticide resistance, climatic events, distractions by other major public health problems such as HIV and tuberculosis, and deteriorating preventive and curative health services, provide no grounds for complacency about malaria in South Africa.
Author Kazeem A. OshikoyaSource: South African Journal of Child Health 3 (2009)More Less
A history of organophosphate exposure may not be evident in neonates presenting with cholinergic symptoms; the effects depend on the type of chemical, its concentration and length of exposure. Exposure can occur in various ways, such as inhalation or absorption through intact skin from contact with contaminated work clothes of an adult, which can explain cases where no pesticides were used in the home.
Source: South African Journal of Child Health 3, pp 5 –8 (2009)More Less
Background. Severe malaria (SM) mortality remains high (10 - 40%) despite treatment. Reports suggest that the World Health Organization-defined SM of 2000 is not a homogeneous group.
Objective. To test the hypothesis that SM patients are heterogeneous, identify criteria that could be used for the grading of SM severity, and propose a method for clinically grading SM in children.
Method. A retrospective study of children aged 3 months to 12 years who fulfilled the WHO SM criteria and were seen at two Nigerian hospitals during a specified period. The presenting clinical features (PCFs) and their calculated case fatality rates (CFRs) were investigated to identify PCFs with the highest CFRs that could be separated from the rest and classified as major PCFs. Major and minor PCFs were used to develop a three-grade system, with analysis of variance (ANOVA) to compare grades.
Results. A total of 8 PCFs were identified in 155 children with SM; impaired consciousness, prostration, convulsions and respiratory distress (in that order) had the highest CFRs (and were designated as major PCFs). The severity grading system was developed using 4 major and 4 minor PCFs as follows: grade I SM - no major, and 1 - 4 minor PCFs; grade II and grade III SM had 1 - 2 and 3 - 4 major PCFs respectively and 1 - 4 minor PCFs (p=0.05).
Conclusion. The proposed severity grading system requires validation by large prospective studies. It is suited for use at the bedside and has the potential to be used in guidelines that are specific to various grades of disease severity and to reduce unnecessary parenteral antimalarials and hospital admission.
Initial treatment of severe malaria in children is inadequate - a study from a referral hospital in CameroonSource: South African Journal of Child Health 3, pp 9 –11 (2009)More Less
Background. Severe malaria, caused by Plasmodium falciparum, is potentially fatal, with a case mortality rate of 15 - 20%, despite treatment.
Aim. To document epidemiological and clinical features, including initial treatment, of severe malaria in children referred to a general paediatric unit in Cameroon.
Methods. A prospective cross-sectional study investigating characteristics of children admitted for severe malaria, confirmed with a positive thick blood smear.
Results. A total of 309 (29.2%) children were identified out of 1 060 admissions, of whom 52% were males and 48% females, and mean age 46.3 (1 - 180) months. Most children were aged <3 years; 43% were 1 - 3 years. The mean duration of symptoms before admission was 3.9 days (range: 1 - 30 days). Hyperpyrexia, severe anaemia and convulsions were the main clinical features in 37%, 32% and 25% cases respectively. In 60% of the subjects, some form of treatment had been administered at home, and 33% had consulted a primary health facility. In 85% of the malaria-infected children, quinine, artemisinin-based combination therapies (ACTs) and amodiaquine were respectively administered to 32%, 30% and 23% of the children. In ACTs-treated patients, 49% received inadequate doses; drugs used in their order of frequency were artemether + lumefantrine (76%), artesunate + amodiaquine (18%), and artesunate + mefloquine (6%). Only 16% of the mothers said they had used insecticide-treated bed nets (ITNs).
Conclusion. In most cases, there is a delay before consultation, with most children initially self-medicated at home. Initial consultations are at primary local health facilities where less effective drugs are prescribed at inadequate dosages. Recommended ACTs were also often prescribed at inadequate dosages. Education in the use of ITNs, home treatment of simple malaria, and appropriate use of ACTs should be promoted.
Factors associated with exclusive breastfeeding among mothers seen at the University of Nigeria Teaching HospitalSource: South African Journal of Child Health 3, pp 14 –19 (2009)More Less
Background. Exclusive breastfeeding (EBF) of babies for 6 months, as recommended by the Baby Friendly Hospital Initiative (BFHI), remains a well-recognised childhood survival strategy of great benefit in reducing infant and under-5 mortality rates.
Objectives. To evaluate the correlation of certain socio-demographic and cultural factors with the ability of mothers to practise EBF for 6 months.
Subjects and methods. Two hundred mothers were interviewed about their knowledge of EBF and their behaviour regarding breastfeeding. The factors associated with constraints on, and motivations for, EBF were tabulated using the chi-square and Student's t-tests.
Results. Of 184 respondents, more than 90% had adequate knowledge of EBF. Thirty-nine (21.2%) practised EBF for all their children, while 95 (51.6%) mothers had never practised EBF with any child. Among those who provided EBF, a high maternal educational level, small family size (≤ 4 children) and absence of opposing family beliefs were important factors. Most subjects were from the upper and middle socio-economic classes (43.6% and 53.8% respectively). Among the 95 women who never attempted EBF, a large family size, personal decision-making and family opposition, especially from grandmothers (41.1%), played significant roles.
Conclusion. The EBF rate in our environment was very low despite a high level of knowledge among mothers. Efforts must be intensified to reiterate the benefits of EBF and address the identified hindrances, via health education of the broader community to enlist family support for breastfeeding mothers. There is also a need for fewer progeny.
Factors affecting HIV-infected mothers' ability to adhere to antenatally intended infant feeding choice in TshwaneSource: South African Journal of Child Health 3, pp 20 –23 (2009)More Less
Objectives. To determine the factors influencing the ability of HIV-infected mothers to adhere to antenatal feeding choices after routine prevention of mother-to-child transmission counselling.
Patients and methods. The postnatal feeding practices of 222 HIV-infected mothers were compared with their prenatal intentions and with those of 53 uninfected mothers.
Results. Ninety-four per cent of HIV-negative mothers were breastfeeding their babies at age 6 weeks, while 69% of HIV-positive mothers were formula feeding. Of the HIV-positive mothers who intended to formula feed prenatally, 25% changed their minds and breastfed, while 50% of 52 women planning to breastfeed switched to formula feeds. Mothers who did not adhere to their original intention to formula feed were significantly younger than those who remained with their original choice, and were more likely to have received negative or domineering support and to share their home with someone other than their partner.
Conclusion. Women are influenced by circumstances in their homes and at the hospital to depart from their original feeding intent.
Discrepant clinical and haematological features in siblings of Pakistani origin with β-thalassaemia : case reportSource: South African Journal of Child Health 3, pp 24 –26 (2009)More Less
An 8-year-old boy was referred with anaemia and splenomegaly. Physical examination revealed short stature, thalassaemic facies, pallor and splenomegaly. The full blood count showed a hypochromic, microcytic anaemia. The serum ferritin level was normal. Haemoglobin electrophoresis revealed 56% HbF, 2.3% HbA2 and 41.7% HbA. The boy's younger sister was subsequently found to have a mild hypochromic, microcytic anaemia with a marked increase in HbF level.
Using the polymerase chain reaction (PCR) and deoxyribonucleic acid (DNA) sequencing, two different β-thalassaemia mutations were identified in the parents. Both parents therefore had a β-thalassaemia trait, while both children were compound heterozygotes.
The propositus had become transfusion dependent while his sister had managed to maintain her Hb above 8.5 g/dl. The family was studied for β+-thalassaemia and hereditary persistence of fetal haemoglobin (HPFH) deletions. This showed that the daughter had inherited a single β-gene deletion from her mother while the son had not. Studies for HPFH mutations revealed that all four family members had one β-point mutation.
The presence of HPFH in this family cannot be considered to have any effect on the thalassaemia major phenotype as neither of these β-mutations are known to be associated with any HbF induction. It is also possible that the daughter inherited a non-deletional HPFH gene which her brother did not.
Source: South African Journal of Child Health 3, pp 27 –30 (2009)More Less
We report on 6 HIV-infected South African children who presented with vasculopathy involving medium and large vessels. Four patients presented with a stroke, one with heart failure and one with gangrene. Five patients had aneurysms and one patient had an occlusion. The arteries of the circle of Willis and the aorta and its major branches were extensively involved. The precise mechanisms of vascular injury in HIV require further study.
Source: South African Journal of Child Health 3 (2009)More Less
A 12-year-old boy who had previously undergone a right ventriculoperitoneal shunt for obstructive hydrocephalus secondary to congenital aqueductal stenosis, presented with headache and vomiting (and no localising neurological signs). The shunt chamber was collapsed and did not fill even after applying pressure. His symptoms were suspected to be the result of shunt malfunction; however, a computed tomography (CT) scan revealed a massive bilateral subdural haematoma (Fig. 1). The child's condition deteriorated, and he developed weakness of the left upper arm, despite a bilateral burr hole and haematoma evacuation. He improved after insertion of a drain into the subdural space and catheter ligation (Fig. 2) and still further when the shunt was replaced with a high-pressure shunt system (Fig. 3). His headache and vomiting subsided, and he remains asymptomatic at follow-up.