Massage therapy improves the development of HIV-exposed infants living in a low socio-economic, peri-urban community of South Africa

The aim of this study was to assess the effect of massage therapy on the growth and development of infants of HIV-infected mothers in a low socio-economic community in Cape Town. It was a prospective, randomised, controlled intervention trial that included massage therapy and control groups of HIV-infected mothers and their normal birth weight infants who were enrolled in the prevention of mother-to-child transmission (PMTCT) programme. Participants were recruited at the 6-week clinic visit and followed up every 2 weeks until their infants were 9 months of age. Mother-infant pairs in the massage therapy and control groups included 73 and 88 at 6 weeks and 55 and 58 at 9 months, respectively. Mothers in the intervention group were trained to massage their infants for 15 min daily. The socioeconomic status, immunity, relationship with the partner and mental pain of mothers; the infants' dietary intake, anthropometry and development (Griffiths Mental Development Scales); and haematological and iron status of mothers and infants were assessed at baseline and follow-up. Nine infants (5.3%) were HIV-infected on the HIV DNA PCR test at 6 weeks. Despite significantly higher levels of maternal mental pain, infants in the massage therapy compared to control group scored higher in all five of the Griffiths Scales of Mental Development and significantly higher in the mean quotient (p=0.002) and mean percentile (p=0.004) for the hearing and speech scale at 9 months. Based on the mean difference in scores, the massage therapy group showed greater improvement for all five scales compared to the control group. The mean difference in scores was significantly greater for the hearing and speech quotient (21.9 vs. 11.2) (p<0.03) and the general quotient percentile (19.3 vs. 7.7) (p=0.03) in the massage therapy compared to the control group. These scales remained significant when adjusting for the relationship with the partner and maternal mental pain. Both groups had lower scores in the performance scale at 9 months although this was significantly worse in the control compared to the massage therapy group when adjusting for maternal CD4 count, anaemia, relationship with the partner and mental pain. There were no significant differences in the anthropometric measurements between the two groups. In conclusion, based on the Griffiths Scales, massage therapy improved the overall development and had a significant effect on the hearing and speech and general quotient of HIV-exposed infants in this study.

The targeting of nutritionally at-risk children attending a primary health care facility in the Western Cape Province of South Africa

AIM

The aim of this study was to determine the practices of primary health care (PHC) nurses in targeting nutritionally at-risk infants and children for intervention at a PHC facility in a peri-urban area of the Western Cape Province of South Africa.

METHODOLOGY

Nutritional risk status of infants and children <6 years of age was based on criteria specified in standardised nutrition case management guidelines developed for PHC facilities in the province. Children were identified as being nutritionally at-risk if their weight was below the 3rd centile, their birth weight was less than 2500 g, and their growth curve showed flattening or dropping off for at least two consecutive monthly visits. The study assessed the practices of nurses in identifying children who were nutritionally at-risk and the entry of these children into the food supplementation programme (formerly the Protein-Energy Malnutrition Scheme) of the health facility. Structured interviews were conducted with nurses to determine their knowledge of the case management guidelines; interviews were also conducted with caregivers to determine their sociodemographic status.

RESULTS

One hundred and thirty-four children were enrolled in the study. The mean age of their caregivers was 29.5 (standard deviation 7.5) years and only 47 (38%) were married. Of the caregivers, 77% were unemployed, 46% had poor household food security and 40% were financially dependent on non-family members. Significantly more children were nutritionally at-risk if the caregiver was unemployed (54%) compared with employed (32%) (P=0.04) and when there was household food insecurity (63%) compared with household food security (37%) (P<0.004). Significantly more children were found not to be nutritionally at-risk if the caregiver was financially self-supporting or supported by their partners (61%) compared with those who were financially dependent on non-family members (35%) (P=0.003). The weight results of the nurses and the researcher differed significantly (P<0.001), which was largely due to the different scales used and weighing methods. The researcher's weight measurements were consistently higher than the nurses' (P<0.00). The researcher identified 67 (50%) infants and children as being nutritionally at-risk compared with 14 (10%) by the nurses. The nurses' poor detection and targeting of nutritionally at-risk children were largely a result of failure to plot weights on the weight-for-age chart (55%) and poor utilisation of the Road to Health Chart.

CONCLUSIONS

Problems identified in the practices of PHC nurses must be addressed in targeting children at nutritional risk so that appropriate intervention and support can be provided. More attention must be given to socio-economic criteria in identifying children who are nutritionally at-risk to ensure their access to adequate social security networks.

Evaluation of a nutrition supplementation programme in the Northern Cape Province of South Africa

AIM

This study aimed at assessing the effectiveness regarding implementation and impact of a take-home nutrition supplementation programme, the Protein Energy Malnutrition (PEM) Scheme, that targets malnourished pre-school children and pregnant and lactating women in the Northern Cape Province of South Africa.

METHODOLOGY

In assessing implementation of the PEM Scheme, a cross-sectional descriptive study was undertaken over a 6-month period in the six regions of the Northern Cape Province. Interviews were conducted with programme managers and health personnel at clinics who were responsible for implementing the PEM Scheme. In assessing the impact of the PEM Scheme on growth, a retrospective review was done of the clinic records (including anthropometric data) of children enrolled in the PEM Scheme over a 1-year period.

RESULTS

About 76% of the budget allocated to the PEM Scheme had been utilised over the 1-year period. The budget for the following financial year was based solely on food supplements purchased in the previous year. Coverage of malnourished pre-school children and eligible pregnant and lactating women for enrolment was estimated to be 50% and 60%, respectively. Eighty-five per cent of health facilities in the province participated in the PEM Scheme. Some of the main problems identified included: lack of training, inappropriate targeting of certain groups, incorrect application especially of discharge criteria for pregnant and lactating women, inadequate assessment for nutrition-related disease, inadequate nutrition counselling and no standardised monitoring. Of the 319 children enrolled over a year, the mean age was 16.2 (standard deviation 16.2) months, 41% had been low-birth-weight and 18% had been diagnosed with tuberculosis. Ten per cent of the children with a weight-for-age Z-score of <-2 moved into the normal Z-score range after being on the PEM Scheme for a mean duration of 8 months. There was an overall improvement in the weight-for-age Z-scores of 25% of the sample, with a significant difference between the mean weight-for-age Z-scores at enrolment and follow-up This was mainly related to significant improvement in the mean weight-for-age Z-scores of children <2 years.

CONCLUSIONS

Numerous problems with the PEM Scheme have been identified which could have limited its impact. Recommendations are proposed for improving the effectiveness and impact of the PEM Scheme in the province.

Epidemiological aspects of liver abscesses in children in the Western Cape Province of South Africa

A high incidence (28 per 100,000 admissions) of liver abscesses is reported in children from the Western Cape Province of South Africa. Of a total of 84 childhood hepatic abscesses over a 10-year period, 51 per cent (43 patients) were primary pyogenic, 30 per cent (25 patients) amoebic, 2 per cent (two patients) Ascaris, and 17 per cent (14 patients) were culture negative. Protein calorie malnutrition was evident in 56 per cent of cases. Amoebic abscesses originated in patients from rural areas, whereas pyogenic abscesses occurred in patients from urban and periurban environments. Staphylococcus aureus was cultured in 85 per cent of pyogenic liver abscesses. Gram negative organisms were identified in four cases of amoebic hepatic abscess where secondary infection occurred. Co-existing parasites of Ascaris lumbricoides and Trichuris trichiura were identified in the stools of 31 per cent of patients. A low (4.8 per cent) mortality is reported for this series.

Pediatric meningitis in the Western Cape Province of South Africa

During the 9 years 1985-1993 a prospective survey of all cases of meningitis in children < 13 years of age presenting to our hospital in the Western Cape Province of South Africa was carried out. Two-thousand-nine-hundred-and-twenty cases of meningitis were identified. The commonest form of bacterial meningitis was tuberculous meningitis (TBM) diagnosed in 282 children (mean age 2.94 years). N. meningitidis identified in 220 children (mean age 2.87 years), Haemophilus influenzae in 156 children (mean age 1.15 years) and S. pneumoniae in 106 children (mean age 2.14) were the next commonest causes of bacterial meningitis diagnosed. One-hundred-and-eighteen cases of bacterial meningitis were confirmed in infants < 1 month of age and the commonest bacteria identified were group B beta-haemolytic Streptococcus in 27, E. coli in 21, Klebsiella species in 11, and Candida species in 15 neonates. The emergence of TBM as the predominant cause of bacterial meningitis in childhood at our hospital is probably a reflection of the worsening tuberculosis situation in the Western Cape Province of South Africa.

Community-acquired Pseudomonas aeruginosa infection in an infant

A 7-month-old infant presented at a tertiary centre with a 6-day history of a skin rash, fever and diarrhoea. Clinical features included pyrexia, kwashiorkor, extensive ulcerating skin lesions suggestive of ecthyma gangrenosum, hepatomegaly, meningismus, neutropenia and iron deficiency anaemia. Blood and skin aspirate cultures yielded a positive growth of Pseudomonas aeruginosa. Apart from severe protein energy malnutrition, no other causes of immunodeficiency were found. He responded well to parenteral antibiotic therapy with gentamicin and piperacillin.

Pharmacokinetics of amikacin in children with kwashiorkor

The pharmacokinetics of intravenous amikacin, administered as a mean (SD) bolus dose of 5.5 (1.2) mg/kg to children between the ages of 1 and 4 years with kwashiorkor, was studied. Although there was a tendency for the average volume of distribution to increase to the upper limit of normal, plasma elimination half-life, first order elimination-phase rate constant and clearance remained close to the reference values for adults. Despite marginal elevation of the average t1/2 beta-value, reflecting a general trend, renal impairment in respect of amikacin clearance could not be demonstrated. It was concluded that the changes in pharmacokinetic parameters found in kwashiorkor are not large enough to amend the current therapeutic regimens for amikacin in this condition.

Rotavirus diarrhoea in Thai infants and children

One hundred and three children aged from 1 month to 5 years were assessed for human rotavirus (HRV) infection over a 5-week period at Children's Hospital, Bangkok. HRV was present in 18% and adenovirus in 10.7% of the children with gastro-enteritis. None of the controls excreted HRV. Vomiting and dehydration were significantly associated with HRV diarrhoea. A comparison of the reliability of the detection methods showed the following sensitivities: RNA-polyacrylamide gel electrophoresis (PAGE) 90%, electron microscopy (EM) 84% and Rotascreen latex particle agglutination (LPA) 80%. PAGE and EM were 100% specific while the Rotascreen LPA was 81% specific. Rotascreen LPA gave 15.5% false positive results. Of the HRV positive samples analyzed by PAGE, 5.3% and 94.7% were of subgroups I and II, respectively. The ID enzyme immunoassay and PAGE are reliable and inexpensive methods which can be recommended for HRV detection, particularly in areas with little technical support.

Brucellosis in childhood in the Western Cape

Human brucellosis, a multisystem disease which may mimic other conditions, has a low incidence in childhood and the diagnosis may easily be missed. Over a 7-month period 9 children with brucellosis presented to the Department of Paediatrics and Child Health, Tygerberg Hospital. Six of the children had consumed unpasteurized milk. The main presenting symptoms were fever, fatigue, headache, myalgia and haematuria. Clinical signs included lymphadenopathy (3), nasopharyngitis (2), features of lower respiratory tract infection (2), splenomegaly (2) and pyrexia (1). The diagnosis was made on the basis of a positive serological titre (> 1:160) for Brucella abortus. The prozone phenomenon was encountered in 6 cases; however, the Coombs test confirmed the diagnosis in these cases. Children under 7 years were treated with co-trimoxazole and rifampicin and those over 7 years with tetracycline and rifampicin, for at least 6 weeks. No relapses were detected on follow-up.