SAJCH Vol 9, No 3 (2015) by HMPG

CHILD HEALTH THE SOUTH AFRICAN JOURNAL OF

August 2015

Volume 9

No. 3

• Preventing GBS disease in South African infants • Severe pneumonia in HIV-infected and exposed infants in a paediatric ICU • Current practices around HIV disclosure to children on HAART • Adherence to case management guidelines of Integrated Management of Childhood Illness by PHC nurses • Effect of a nutrition education programme on nutritional status of children

CHILD HEALTH THE SOUTH AFRICAN JOURNAL OF

August 2015

Volume. 9

No. 3

CONTENTS

EDITOR J M Pettifor FOUNDING EDITOR N P Khumalo EDITORIAL BOARD: SAJCH Prof. M Adhikari (University of KwaZulu-Natal, Durban) Prof. M Kruger (Stellenbosch University) Prof. H Rode (Red Cross Hospital, Cape Town) Prof. L Spitz (Emeritus Nuffield Professor of Paediatric Surgery, London) Prof. A Venter (University of the Free State, Bloemfontein) Dr T Westwood (Red Cross Hospital, Cape Town) Prof. D F Wittenberg (University of Pretoria)

Editorial

Z Dangor, S G Lala, S A Madhi

Conference Report

CEO AND PUBLISHER Hannah Kikaya

H Saloojee, N McKerrow, A van der Vyver

Articles

EDITOR-IN-CHIEF Janet Seggie

H C Weber, R P Gie, K Wills, M F Cotton

EXECUTIVE EDITOR Bridget Farham

Severe pneumonia in HIV-infected and exposed infants in a paediatric ICU

J Cloete, P Becker, R Masekela, A Pentz; W Wijnant, R de Campos, O P Kitchin, R J Green

MANAGING EDITOR Ingrid Nye

Parents’ journey into the world of autism

A Alli, S Abdoola, A Mupawose

69 Preventing invasive Group B Streptococcus (GBS) disease in South African infants: Time for change

HEALTH & MEDICAL PUBLISHING GROUP:

The 5th South African Child Health Priorities Conference

Clinical features and lung function in HIV-infected children with chronic lung disease

TECHNICAL EDITORS Emma Buchanan Paula van der Bijl

85 Current practices around HIV disclosure to children on highly active antiretroviral therapy

G D Naidoo, N H McKerrow

89 Adherence to case management guidelines of Integrated Management of Childhood Illness (IMCI) by healthcare workers in Tshwane, South Africa

CONSULTING EDITOR J P de V van Niekerk

M C Mulaudzi

PRODUCTION MANAGER Emma-Jane Couzens DTP, LAYOUT & SETTING Carl Sampson DISTRIBUTION MANAGER Edward Macdonald HEAD OF SALES AND MARKETING Diane Smith (012) 481 2069 | dianes@samedical.org

93 Viability in delivering oral health promotion activities within the Health Promoting Schools Initiative in KwaZulu-Natal

ISSN 1994-3032

JOURNAL WEBSITE: www.sajch.org.za

M Reddy, S Singh

98 Effect of a nutrition education programme on nutritional status of children aged 3 - 5 years in Limpopo Province, South Africa

L F Mushaphi, A Dannhauser, C M Walsh, X G Mbhenyane

Case Report

O F Adeniyi, J K Renner

105

CPD Questions

103 Food allergy: Two case reports and management challenges in a resource-limited setting

ublished by Health and Medical Publishing Group, P Suites 9 & 10, Lonsdale Building, Gardner Way, Pinelands 7405 apers for publication should be addressed to the Editor, P via website: www.sajch.org.za Tel: 072 635 9825 E-mail: publishing@hmpg.co.za Cover: by Chante, Red Cross War Memorial Children's Hospital Primary School

©Copyright: Health and Medical Publishing Group (Pty) Ltd

Manuscripts containing plagiarism will not be considered for publication in the SAJCH. For information on our plagiarism policy, please visit the editorial policy section on our website. (http://www.sajch.org.za/index.php/ sajch/about/editorialPolicies)

GUEST EDITORIAL

Preventing invasive Group B Streptococcus (GBS) disease in South African infants: Time for change Streptococcus agalactiae is an encapsulated Gram-positive coccus that colonises the gastrointestinal and genito urinary tracts. This organism belongs exclusively to Group B in Lancefield’s grouping of Streptococcus species and therefore is referred to as Group B Streptococcus (GBS). Of the ten known serotypes, serotypes Ia and III account for most disease. The greatest burden of invasive GBS disease is seen in infants <3 months of age, although GBS can cause disease in adults and pregnant women. Disease manifesting in the first 6 days of life is referred to as early-onset disease (EOD), whereas late-onset disease (LOD) manifests from day 7 - 89 of life. Approximately 10 - 40% of pregnant women are colonised, rectally and/or vaginally, with GBS. About 30 - 70% of newborns become colonised with GBS in utero or during delivery, and invasive disease occurs in 1 - 3% (probably from aspiration of infected amniotic fluid or genital secretions). [1] Most EOD (>90%) manifests at birth, with signs of respiratory distress or sepsis. Furthermore, there is a strong association between GBS disease and stillbirth.[2] In contrast, LOD occurs through horizontal transmission via the faecal-oral route (the mother is usually the source), through infected breastmilk, or rarely, through nosocomial spread. These infants may develop sepsis, meningitis (~50%), septic arthritis, osteomyelitis or cellulitis. The global incidence (per 1 000 live births) of invasive GBS disease in infants <90 days of age is estimated to be 0.53 (95% confidence interval (CI) 0.44 - 0.62) with a case fatality ratio of 9.6%.[3] In South Africa (SA), the high incidence rate has remained largely unchanged at 2 - 3 per 1 000 live births over the last two and half decades,[4-7] although it is reportedly lower in the Western Cape (0.67 per 1 000 live births). [8] Of concern, the high incidence is also associated with a high case fatality ratio (13 - 18%) and there is significant neurological impairment among survivors, especially in those with meningitis (24%).[7] Worldwide, the highest incidence of invasive GBS disease is reported in SA;[9] this is likely to contribute to the high neonatal mortality rate and our subsequent failure to reach the targeted goal of reducing under-five childhood mortality (Millenium Development Goal 4). Trends in the incidence of invasive GBS disease in Soweto from 1997 to 2013 have highlighted that

suboptimal implementation of intrapartum antibiotic prophylaxis (IAP) to women identified to be at risk of having infants with EOD, coupled with maternal HIV infection being associated with a two-to-five-fold greater risk of invasive GBS disease in infants, has contributed to the country persistently reporting the high rates of invasive GBS disease.[6,7] The increased susceptibility to invasive GBS disease in infants born to HIV-infected women is thought to be due to lower maternal protective GBS capsular antibody concentrations and the inefficient transplacental transfer thereof.[10] In the USA, the incidence of EOD has declined significantly (>80%) since the early 1990s through effective execution of secondary preventative strategies, i.e. antibiotics administered intravenously 4 hours before delivery to GBS-colonised women who were screened at 35 - 37 weeks’ gestation.[1] This universal screening approach (as recommended by the Centers for Disease Control (CDC)) cannot be readily implemented in most low-to-middleincome countries, where a large proportion of deliveries occur outside health facilities, although this is not the case in SA. In addition, the high cost of screening pregnant women, providing IAP and creating the necessary infrastructure that enables the administration of intravenous IAP at least 4 hours prior to delivery has hampered preventive efforts in low-to-middleincome countries. Furthermore, the CDC recommendation has limitations such as false-negative cultures in colonised pregnant

women, failure to institute IAP for sudden deliveries, the risk of penicillin resistance and the limited effect of IAP on preventing preterm delivery, stillbirths and LOD.[1] Currently, most low-to-middle-income counties, including SA and some European countries, practise the less successful riskbased approach to prevent invasive disease, i.e. IAP is only provided to mothers in labour with risk factors such as maternal fever, prolonged rupture of membranes or prematurity. This strategy is also failing in low-to-middle-income countries because risk factors do not identify all women who are at risk of transmitting GBS. Furthermore, healthcare workers may fail to recognise risk factors, and may not provide IAP in busy obstetric units. Other proposed preventive strategies, including chlorhexidine vaginal wipes, do not prevent EOD. Rapid molecular diagnostic tests to detect maternal GBS colonisation during labour is promising but costly, and the struggle for most low-tomiddle-income countries remains the timely and effective administration of IAP, thus rendering molecular tests futile in these settings. The above limitations, as well as the failure to implement these strategies in low-to-middle-income countries, calls for a paradigm shift regarding the future prevention of invasive GBS disease. Vaccinating pregnant women in the second trimester of pregnancy could result in an increase in maternal antibody levels, which in turn may be transferred to the fetus in the last trimester. This strategy

Table 1. Antibiotic therapy in infants with invasive GBS disease Clinical presentation

Penicillin G Ampicillin (mg/ (units/kg per day)* kg per day)

Duration of antibiotics (days)

Bacteraemia without a focus

75 000 - 150 000

100 - 200

10 - 14

Sepsis

75 000 - 150 000

100 - 200

10 - 14

Pneumonia

75 000 - 150 000

100 - 200

10 - 14

Urinary tract infection

75 000 - 150 000

100 - 200

10 - 14

Cellulitis

75 000 - 150 000

100 - 200

10 - 14

Septic arthritis

75 000 - 150 000

100 - 200

14 - 21

Osteomyelitis

75 000 - 150 000

100 - 200

21 - 28

Meningitis

450 000 – 500 000

200 - 300

*The recommended dosing interval for Penicillin G is 8 or 12 hourly, except for meningitis, for which the recommendation is 6 hourly. For early-onset meningitis, the dose of Penicillin G is 250 000 - 450 000 units/kg per day divided every 8 hours for the first week of life. The recommended dosing interval for ampicillin is 6 hourly, except during the first week of life where the recommendation is 8 or 12 hourly. Gentamicin 5 mg/kg/day for 5 days can be used for synergy in cases of meningitis.

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GUEST EDITORIAL has been successfully used for the prevention of tetanus, influenza and pertussis in infants.[11] A trivalent GBS polysaccharide-protein conjugate vaccine (against serotypes Ia, Ib and III) has completed phase-II evaluation among pregnant women and has the potential to prevent 70 - 80% of all invasive GBS disease. Maternal GBS vaccination is potentially cost effective and easy to implement in low-to-middle-income settings; furthermore, vaccination during pregnancy is becoming more acceptable to the public. For those infants who require treatment for invasive GBS disease, penicillin remains the drug of choice (Table 1). There is no role for the use of immunoglobulins or dexamethasone in infants with meningitis. Recurrence of invasive GBS disease may occur in 1 - 2% of infants despite adequate treatment. In conclusion, GBS is the most common cause of neonatal sepsis and meningitis. SA has a very high incidence of invasive GBS disease and the provision of IAP is practically difficult; maternal GBS vaccination is a promising strategy. Z Dangor,1,2,3 S G Lala,1 S A Madhi2,3,4 Department of Paediatrics and Child Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa 2 Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Johannesburg, South Africa 3 Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa 4 National Institute for Communicable Diseases: A division of National Health Laboratory Service, Johannesburg, South Africa 1

Financial disclosure/support. ZD is funded in part by the Carnegie Corporation of New York (Grant number B8749) and the Discovery Foundation (Grant number 20289/1). SAM is funded in part by National Research Foundation/Department of Science and Technology: South African Research Chair Initiative in Vaccine Preventable Diseases and

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Medical Research Council of South Africa. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Corresponding author: Z Dangor (ziyaad.dangor@wits.ac.za) 1. Verani JR, McGee L, Schrag SJ. Prevention of perinatal group B streptococcal disease: Revised guidelines from CDC, 2010. Mor Mortal Wkly Rep 2010;59(RR-10):1-36. 2. Nan C, Dangor Z, Cutland CL, Edwards MS, Madhi SA, Cunnington MC. Maternal group B Streptococcus-related stillbirth: A systematic review. BJOG 2015 (in press). [http://dx.doi.org/10.1111/1471-0528.13527] 3. Edmond KM, Kortsalioudaki C, Scott S, et al. Group B streptococcal disease in infants aged younger than 3 months: Systematic review and metaanalysis. Lancet 2012;379(9815):547-556. [http://dx.doi.org/10.1016/S01406736(11)61651-6] 4. Haffejee IE, Bhana RH, Coovadia YM, Hoosen AA, Marajh AV, Gouws E. Neonatal group B streptococcal infections in Indian (Asian) babies in South Africa. J Infect 1991;22(3):225-231. 5. Madhi SA, Radebe K, Crewe-Brown H, et al. High burden of invasive Streptococcus agalactiae disease in South African infants. Ann Trop Paediatr 2003;23(1):15-23. [http://dx.doi.org/10.1179/000349803125002814] 6. Cutland CL, Schrag SJ, Thigpen MC, et al. Increased risk for Group B Streptococcus sepsis in young infants exposed to HIV, Soweto, South Africa, 2004 - 2008. Emerg Infect Dis 2015;21(4):638-645. 7. Dangor Z, Lala SG, Cutland CL, et al. Burden of invasive Group B Streptococcus disease and early neurological sequelae in South African infants. PloS ONE 2015;10(4):e0123014. [http://dx.doi.org/10.1371/journal.pone.0123014] 8. Frigati L, van der Merwe JL, Harvey J, Rabie H, Theron G, Cotton MF. A retrospective review of Group B streptococcal infection in the Metro East area of the Western Cape province: 2010 - 2011. S Afr J Infect Dis 2014;29(1):33-36. 9. Dagnew AF, Cunnington MC, Dube Q, et al. Variation in reported neonatal group B streptococcal disease incidence in developing countries. Clin Infect Dis 2012;55(1):91-102. [http://dx.doi.org/10.1093/cid/cis395] 10. Dangor Z, Kwatra G, Izu A, et al. HIV-1 is associated with lower Group B Streptococcus capsular and surface-protein IgG antibody levels and reduced transplacental antibody transfer in pregnant women. J Infect Dis 2015;212(3):453-462. [http://dx.doi.org/10.1093/infdis/jiv064] 11. Steinhoff MC. Assessments of vaccines for prenatal immunization. Vaccine 2013;31(Suppl 4):D27-30. [http://dx.doi.org/10.1016/j.vaccine.2013.02.031]

S Afr J Child Health 2015;9(3):69-70. DOI:10.7196/SAJCH.8575

AUGUST 2015 Vol. 9 No. 3

CONFERENCE REPORT The 5th South African Child Health Priorities Conference

The 5th South African (SA) Child Health Priorities Conference was convened by the SA Child Health Priorities Association at the University of the Free State in Bloemfontein from 3 to 5 December 2014. The conference theme was ‘Closing the Gaps – Beyond Child Survival’. A well-constructed conference programme encouraged partici pants to move away from traditional notions focused on child survival and the absence of disease towards reflecting on how best to promote the wellbeing, resilience and capability of the country’s children. In the course of the conference, three subthemes emerged: taking stock of child survival in SA and enhancing local initiatives to improve this; the potential of early childhood development (ECD) activities to close existing gaps; and a long-overdue appreciation of the importance of social, adolescent and mental health. The conference opening addresses from Dr Bhardwaj (from UNICEF) and Dr Matela (Free State Provincial Paediatrician), reviewed both global and local progress in child survival as the Millennium Development Goals (MDGs) 2015 endpoint nears. Despite a doubling in the rate of reduction of under-five mortality in countdown countries between 2000 and 2012 compared with 19902000, and a halving of child deaths since 1990, more than half of the 62 countdown countries, including SA, are unlikely to achieve their MDG child mortality targets. A decline in the under-five and infant mortality rates continues in SA, albeit at a slower pace, but the neonatal mortality rate is unchanged and fluctuates around 12 per 1 000 births. Dr Bhardwaj emphasised that maintaining the current momentum requires ruthless prioritisation of quality delivery at full scale for a small number of interventions that address the major causes of child deaths. Fortunately, early drafts of the next global step, the Sustainable Development Goals (SDGs), retain the healthrelated MDGs as a subset of their proposed health-related goals. Drs Bhardwaj and Saloojee provided feedback on an independent mid-term review commissioned by the national Department of Health, of the department’s Maternal, Newborn, Child and Women’s Health and Nutrition (MNCWH&N) 20122016 strategic plan. The evaluation found limited progress in health system functional effectiveness, with, for example, lengthy and cumbersome procurement and human resources processes resulting in stock-outs of medicines and supplies, and shortages of critical staff. Swifter decentralisation of responsibility was identified as a key response. Some progress was noted in organisational and political effectiveness. Improved

communication of key messages to staff and the public was another activity identified as requiring substantial attention. The review’s recommendations focus on the need for all health workers to know their own issues, track responses, be accountable, foster teamwork and get the basics right while actively connecting components of the health system (through activities such as facilitating effective transport and referrals). ECD, first introduced as a theme at the 2012 conference, was once again a focus at this conference. Ms Slemming reviewed the background, development and future of the ECD policy and plans for the country. She emphasised the central role of ECD in the realisation of the national development plan goal to reduce poverty and inequality in the country, and highlighted the five priority areas of the ECD plan: family, home and centre-based support; nutrition; early learning opportunities; support for children with disabilities; and improved public communication. Cabinet was considering adopting a national ECD policy. (Update: A draft ECD policy was gazetted by government in March 2015). A presentation on how best to reduce a key ECD target - stunting in SA - emphasised that nutrition-specific interventions alone are almost certainly insufficient, and nutrition-sensitive development needs to be fostered. Lessons learnt from the KwaZulu-Natal experience in introducing an infant and child feeding policy were also presented. The third subtheme of the conference introduced participants to issues related to social, mental and adolescent health. A moving case report from Universitas Hospital highlighted the value of palliative care in the holistic care of children with malignancies. Prof. Nicol and Ms Mabizela, respectively, considered the predisposing factors, context and spectrum of childhood mental disorders and an approach to addressing these within the Free State health service. Dr Rabie used her experience in an adolescent HIV clinic to highlight the complexities, challenges and rewards of caring for adolescent patients. The role of child health screening in the SA context was debated, and despite well-considered arguments from advocates of specific child screening programmes, it was evident that these cannot be justified merely because there is a problem or a suitable test available. The potential for a functional system has to be present to ensure that the benefits of screening outweigh the costs. Few screening procedures meet this criterion in the local context. A conference highlight for many was a session where adolescents with two chronic diseases - diabetes mellitus and HIV – reflected on the effect of the illness on their lives and offered frank and insightful answers to questions from the audience. On a lighter note, this was possibly the first conference where participants had to sing to retain their seats when Prof. Westwood introduced the Western Cape’s approach to promoting the use of the Road to Health Book as a child’s passport to health. Conference participants boisterously sang the initiative’s pledge song to the tune of Paul McCartney’s frog song, We All Stand Together. The SA Child Health Priorities Association is a child health advocacy group, providing for interaction of child health professionals from a variety of fields (such as health, social development and law). The next Child Health Priorities conference is scheduled for Pietermaritzburg in December 2015, with Cape Town being the likely venue in 2016. Visit the Association’s website http:// childhealthpriorities.co.za for details, and to view PowerPoint presentations from the 2014 conference. H Saloojee, N McKerrow, A van der Vyver

Fig. 1. Western Cape Department of Health pledge whereby signatories undertake to support and promote the Road to Health Book as a children’s passport to good health.

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S Afr J Child Health 2015;9(3):71. DOI:10.7196/SAJCH.8367

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ARTICLE

Clinical features and lung function in HIV-infected children with chronic lung disease H C Weber,1 MB ChB, DCH(SA), MMed (Paed), FC Paed (Cert Pulmonology), Dip Allerg (SA), FRACP, MPH; R P Gie,2 MB ChB, FCP; K Wills,3 PhD; M F Cotton,2,4 MB ChB, DTM&H, FCP, PhD Faculty of Health, School of Medicine, University of Tasmania, Burnie, Australia Department of Paediatrics and Child Health, Stellenbosch University, South Africa 3 Menzies Research Institute, University of Tasmania, Hobart, Australia 4 KID-CRU Research Institute, Cape Town, South Africa 1 2

Corresponding author: H C Weber (heinrich.weber@ths.tas.gov.au)

Background. Although chronic lung disease (CLD) is commonly seen in children with advanced HIV disease, it is poorly studied. Objectives. To report on the clinical manifestations and lung function tests in children with advanced HIV disease at a tertiary care centre, and determine clinical predictors of poor lung function. Methods. We undertook a cross-sectional study of children with advanced HIV disease in whom CLD was suspected. We undertook clinical evaluation and lung function tests, accompanied by a retrospective chart review. Results. In 56 children identified, the median age was 5 (interquartile range (IQR) 2 - 8) years with equal gender ratio. The majority (93%) had been previously treated for tuberculosis and/or pneumonia (71%). The most common CLD identified was lymphocytic interstitial pneumonitis (54%). The median nadir CD4 percentage was 13% (IQR 8.5 - 16%) and the median highest reported viral load was log5.8 (IQR log5.0 - log6.5). The median duration of antiretroviral therapy was 9.8 (IQR 1.1 - 19.5) months. Lung function tests were performed in 27 (48%) children. The median forced expiratory volume in 1 second (FEV1) was 60% (IQR 45.3 - 86.3%) predicted. Previous hospitalisation, respiratory rate, digital clubbing, chest hyperinflation and hyperpigmented skin lesions were associated with a decreased FEV1 in a univariate relationship. In a multiple linear regression analysis, hyperinflation, increased respiratory rate and hyperpigmented skin lesions were associated with poor lung function (percentage FEV1). Conclusion. We identified useful clinical signs predictive of poor lung function in HIV-infected children with CLD, especially in resourcelimited settings. S Afr J Child Health 2015;9(3):72-75. DOI:10.7196/SAJCH.7940

The majority (>90%) of paediatric HIV infections occur in sub-Saharan Africa.[1,2] In South Africa (SA), programmes to reduce vertical transmission began in 2003, with combination antiretroviral therapy (cART) becoming available in the public sector in 2004. Many children in whom cART was initiated already had advanced HIV disease. Early ART from 7 to 8 weeks of age was only instituted in 2010.[3] Respiratory disease is a major cause of morbidity and is the most important cause of mortality in HIV-positive children.[4] A high prevalence of chronic lung disease (CLD) was recently recognised in perinatally infected adolescents.[5] There are no uniform diagnostic criteria for CLD in children. [6-13] Chronic respiratory symptoms such as a chronic cough for at least 3 months of the year, or cough with associated symptoms and chronic radiological signs have been used.[7] In a recent study of CLD in HIV-infected adolescents, the diagnostic criteria for CLD included a combination of symptoms, clinical signs, radiological manifestations, exercise tests, oxygen saturations, spirometry and echocardiographic findings.[5] In this study, at least a third of patients with chronic respiratory impairment would not have been identified had cough-predominant diagnostic criteria been used. Many diagnostic investigations required to substantiate the diagnosis are often unavailable in the areas most affected by HIV. Also, tests to separate cardiovascular from respiratory causes cannot always be performed. Additional clinical predictors of chronic respiratory impairment could be useful in resource-limited settings to enable healthcare workers to recognise children with CLD. 72

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There are a few studies of CLD in HIV-infected children and adolescents. In a narrative review, the most likely aetiologies included pulmonary tuberculosis (PTB), lymphoid interstitial pneumonitis (LIP), persistent or recurrent pneumonia and bronchiectasis. [12] More recently, small airway disease has been described in adolescents. [5] Other aetiologies include interstitial lung disease (ILD) and malignancy.[12] In a study by Jeena et al.,[7] predating cART availability, 71% of young children investigated for persistent lung disease (defined as persistence of clinical and radiological findings after at least 1 month of initial treatment) were HIV-infected. In those with symptoms for more than 3 months, LIP (57%) was the most important cause, followed by PTB (29%). A review of the chest radiographs of HIV-infected children in the USA, again predating early cART, showed that chronic radiological changes had a cumulative incidence of 33% by 4 years of age.[11] More recently, Pitcher et al.[14] showed that in children with a median age of 23.8 months and limited access to cART, only 16% of 330 children from Cape Town had normal chest radiographs, with 169 (51%) having severe radiological abnormalities.

Objective

To describe the symptoms, signs and lung function in HIV-infected children evaluated for CLD seen at Tygerberg Children’s Hospital in Cape Town, Western Province, SA, a region with a high prevalence of both HIV and TB.

Methods

Subjects in whom CLD was suspected because of chronic symptoms and/or signs or with a history of recurrent pneumonia participated

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ARTICLE in a cross-sectional study. Clinical evaluation and lung function tests were accompanied by a complete retrospective chart review. The clinical evaluations were performed over 10 months, from May 2005 to February 2006. The definition used for CLD disease was a chronic cough and/or respiratory or radiological signs present for at least 3 months. Vital signs were obtained from the clinical charts on the same day that a single investigator (H C Weber) undertook the clinical examination. Transcutaneous oxy gen saturation measurements were not consistently taken and were therefore excluded from analysis. The World Health Organization (WHO) growth standards were used for weight-for-age z-scores (WAZ), height-for-age z-scores (HAZ) and weight-for-height z-scores (WHZ). Children with z-scores two standard deviations (SDs) below the mean WAZ were classified as underweight and two SDs below the mean HAZ were classified as stunted.[15] The lowest recorded CD4 percentage and highest recorded log viral load (VL) were obtained from clinical records. A Jaeger Masterscreen pneumotachometer system (Erich Jaeger, Germany), with daily volume calibration as per American Thoracic Society (ATS)/European Respiratory Society (ERS) protocol was used for lung function tests.[16] Ability to perform adequate lung function tests was determined by the child’s ability to produce an acceptable flow volume loop according to ATS/ERS criteria.[16] The highest forced expiratory volume in 1 second (FEV1) value was recorded and Polgar’s equation was used to calculate reference values. [17] Background and clinical characteristics were summarised using frequency and percentage for categorical data, and median and interquartile range (IQR) for continuous data. A respiratory rate ratio was developed to allow comparison of respiratory rates across different age groups. Each child’s respiratory rate was divided by the upper limit of normal respiratory rate for that age. [18] Spearman’s correlation coefficients were used to measure the associations between the percentage predicted FEV1 (FEV1%) and clinical characteristics measured on a continuous scale. For continuous variables, mean FEV1% was compared using t-tests. Univariable and multivariable linear regressions were used to determine predictors for poor outcome in lung function tests. Factors most strongly associated with FEV1% in univariable analysis were retained for the multivariable analyses. The data were entered into an Access (Microsoft, USA) database, and all the statistical procedures were performed using STATA statistical software, version 10 (StataCorp, USA). Tests

of significance were two-tailed, and a p-value <0.05 was considered significant. Informed consent was obtained from the parents or legal guardians of the children. Institutional Review Board approval was obtained from the Health Research Ethics Committee at Stellenbosch University.

Results

Clinical features

Fifty-six children were studied. Table 1 shows the baseline demographic and clinical characteristics. Median age was 5 years. Of the 36 cases previously hospitalised for pneumonia, 27 (74%) had two or more and

13 (37%) had three or more hospitalisations. The majority (93%) had been previously treated for PTB, 60% on two or more occasions. Forty-seven per cent were stunted and 31% were underweight for age. The median period on ART was 9.8 (IQR 1.1 - 19.5) months. There was documenta tion of inhaled bronchodilator use in 8 (16%) and inhaled corticosteroids in 5 (10%) children.

Lung function

Twenty-seven children (48%) performed adequate lung function tests. The median FEV1% was 60% (IQR 45.3 - 86.3%). Only

Table 1. Demographic data, background information, associated diagnoses and laboratory findings of HIV-infected children (N=56) Demographic data

Total group, n* (%)

Lung functions only, n (%)

Total

Age (years), median (IQR)

5 (2 - 8)

6 (3 - 8)

Gender (male)

30 (53.6)

13 (48.2)

Pneumonia requiring hospitalisation 36 (64.0)

15 (55.6)

Previous TB

50/54 (92.6)

25 (92.6)

Exercise limitation

28/53 (52.8)

17 (65.4)

Wheezing

35/54 (64.8)

16 (59.3)

Snoring

23/49 (46.9)

12 (50.0)

Any smoking exposure at home

24/53 (45.3)

13 (48.2)

Recurrent pneumonia

25/53 (47.2)

10 (40.0)

Dental caries

14/40 (35.0)

6 (33.3)

Digital clubbing

23/52 (44.2)

13 (52.0)

WAZ, median (IQR)

–1.92 (–2.65 - –0.77)

–1.45 (–2.95 - –0.46)

HAZ, median (IQR)

–1.39 (–2.16 - –0.73)

–1.40 (–2.15 - –0.85)

WHZ, median (IQR)

0.09 (–0.82 - 0.65)

0.01 (–0.80 - –0.70)

Wheeze

5/54 (9.3)

3 (11.5)

Hyperinflation

28/52 (53.8)

14 (56.0)

Respiratory rate ratio, median (IQR)

1.10 (0.96 - 1.36)

1.16 (0.80 - 1.36)

Gastro-oesophageal reflux

5/53 (9.4)

2 (8.0)

Failure to thrive

11/52 (21.2)

6 (24.0)

Developmental delay

9/53 (17.0)

4 (16.0)

Hyperpigmented skin lesions

15/51 (29.4)

7 (29.2)

Asthma

8/56 (14.3)

7 (25.9)

LIP

28/52 (53.8)

18 (75)

CD4%, median (IQR)

13 (8.5 - 16)

13 (8.5 - 15.8)

VL (log), median (IQR)

5.84 (4.97 - 6.48)

5.94 (5.58 - 6.54)

Background information

Clinical characteristics

Associated diagnoses

Laboratory

WAZ = observed weight – median weight of the reference population / standard deviation value of reference population; HAZ = observed height – median height of the reference population / standard deviation value of reference population. *Equation used where denominator differed from total number of subjects in study (N=56).

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ARTICLE 5 (18.5%) had a positive bronchodilator response (FEV1% increase ≥12% post bronchodilator). Clinical signs associated with FEV1% in a univariate relationship included admission for pneumonia, respiratory rate, clubbing, hyperinflation and hyperpigmented skin lesions. There was a significant negative association between respiratory rate (respiratory rate ratio) and lung function (FEV1%), indicating that a higher respiratory rate was associated with lower FEV1% (Fig. 1). All but one child with FEV1% <60% predicted had a respiratory rate at the upper limit of normal for age (respiratory rate ratio >1). The final regression model for clinical signs associated with lung function outcome (FEV1%) is shown in Table 2 (p<0.001, adjusted R2=0.68). Although respiratory rate ratio was not statistically significant in the final model (p=0.10), it was retained owing to its clinical relevance and the significant univariate relationship with

120

FEV1%

100 80 60 40 20 0.5

1.0 1.5 Respiratory rate ratio

2.0

Fig. 1. Scatter plot of FEV1% v. respiratory rate ratio (correlation coefficient = –0.53, p=0.007).

Table 2. Relationship between FEV1% and clinical variables Variable

Test statistic / mean difference (95% CI)*

p-value

Respiratory rate ratio

–0.65

0.007

WAZ

0.09

0.702

HAZ

0.31

0.148

WHZ

0.25

0.262

VL (log)

0.06

0.881

CD4%

0.35

0.089

Age

–0.01

0.958

cART duration

–0.05

0.801

Admitted for pneumonia

20.5 (2.2 - 38.9)

0.030

Exercise limitation

14.8 (–5.8 - 55.4)

0.152

Snoring

8.8 (–13.1 - 29.5)

0.423

Clubbing

20.2 (1.0 - 39.4)

0.040

Wheezing

–10.3 (–30.3 - 9.7)

0.298

Hyperinflation

25.0 (6.5 - 43.5)

0.010

LIP

18.1 (–6.5 - 42.6)

0.141

Hyperpigmented skin lesions

22.9 (0.8 - 45.0)

0.043

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Discussion

There are very few clinical descriptors of clinical and lung function parameters in HIV-infected children with CLD. This study highlights uniformly poor lung function and some clinical markers for poor respiratory function in these children. Multiple linear regression analyses indicate that ratios comparing respiratory rate with the upper limit of normal for age, hyperinflation and hyperpigmented skin lesions are potential indicators of poor lung function. The epidemiology of CLD in HIV-infected children and adolescents is poorly described. Ferrand et al.[5] reported an 86% prevalence of CLD in Zimbabwean adolescent survivors of perinatal HIV infection. Rylance et al.[19] similarly described respiratory impairment in a group of Malawian HIV-infected adolescents. Our case series is in pre-adolescents, suggesting that CLD is already well established in childhood. Children and adolescents with CLD most likely represent ‘slow progressors’ with a more gradual onset of immunosuppression after perinatal infection. PTB was the most frequent comorbid illness in our study (92%), with most (60%) requiring anti-TB treatment on two or more occasions. Neither the temporal relationship between PTB and CLD nor the accuracy of the PTB diagnosis could be established. In adolescents with CLD, small-airway disease with concomitant bronchiectasis was the main pathological abnormality, more frequent than PTB and LIP.[5] Overdiagnosis of PTB could account for the high prevalence of previous PTB in our study. Clinicians should be alerted to identifying HIV-infected children and adolescents at increased risk of CLD. Factors identified in the history of the patient include a background of recurrent respiratory tract infections (47% in our study) or pneumonia. Similarly, in a case-controlled study evaluating risk factors for bronchiectasis in HIV-infected children, 89.5% of those with bronchiectasis had a history of recurrent pneumonia v. 8.8% in the control group (p≤0.001).[20] Additional aggravating factors identified were exposure to tobacco smoke (46%), dental caries (30%) and gastro-oesophageal reflux (7%), all being opportunities for intervention to limit further lung damage. In a recent review we discussed the challenges of CLD and some potential treatments, such as aggressive antibiotic therapy and regular immunisations.[21] Table 3. Final model for multivariable linear regression analysis of factors associated with reduced FEV1% in HIV-infected children

*Spearman rank correlation reported for continuous variables and mean difference (95% CI) reported for categorical variables.

FEV1%. A unit increase in respiratory rate ratio, in the absence of other risk factors, was associated with a 26% reduction of estimated FEV1%. The presence of hyperinflation, in the absence of other risk factors, was associated with a 40% reduction in estimated FEV1%. Hyperpigmented skin lesions alone, an easily recognisable clinical marker, was associated with a 34% reduction in FEV1%. The predictive values of hyperpigmented skin lesions and hyperinflation are not unique as there is significant interaction between these factors. FEV1 in one subject, having high influence relative to all other observations, was determined to be an outlier. After refitting the regression model without this observation, our substantive conclusions did not change (adjusted R2=0.82, p<0.001). However, respiratory rate ratio reached statistical significance (p=0.018). The outlier observation was retained in the final regression model.

Variable

β (95% CI)

p-value

Respiratory rate ratio

–25.7 (–57.4 - 5.87)

0.103

Hyperinflation

–40.5 (–59.6 - –21.3)

0.000

Hyperpigmented skin lesions

–33.5 (–56.8 - –10.2)

0.008

Hyperinflation and hyperpigmented skin lesions

38.8 (3.80, 73.8)

0.032

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ARTICLE In the current study, 53% of patients had a history of impaired effort tolerance, similar to that reported in HIV-infected adolescents. [5,15] Other associated symptoms included previous wheezing (65%) and snoring (47%). A significant proportion (>40%) of HIV-infected adolescents with CLD had hypoxia, either at rest or with exercise. [5,14] In addition, Ferrand et al.[5] documented echocardiographic evidence of pulmonary hypertension in 7% of adolescents with CLD. Additional cardiac abnormalities are common in HIV-infected adolescents, with 67% having echocardiographic evidence of left ventricular hypertrophy.[22] Hypoxia and cardiac involvement are common in HIV-infected children and adolescents, and their evaluation should be a major priority. Our case series most likely represents the worst end of the spectrum, given that the median FEV1% of 60% of the expected value was used as the ‘norm’ for comparison. It is likely that routine lung function tests and more sensitive tests of exercise impairment will identify more subtle effort intolerance. This study identified useful clinical associations with poor lung function, i.e. respiratory rate, hyperinflation and hyperpigmented skin lesions. Of note, the degree of immunosuppression (CD4%) and VL were not associated with lung function in this study as in other paediatric adolescent studies.[5,22] The origin of the hyperpigmentation is uncertain and could represent many causes, such as impetigo, papular pruritic eruption and fungal infections. In our experience, papular pruritic eruption occurs commonly in HIV-infected children, and it is a stage 2 WHO criterion frequently seen with more advanced disease and immunosuppression.[23-25] The clinical signs identified could be additional pointers to CLD, alerting clinicians to a need for further investigation. The absence of a bronchodilator response, in 81.5% in our series, has been noted elsewhere and supports the diagnosis of non-reversible small-airway disease.[18] The role of cART and other medications in managing and preventing CLD requires further study. Although the duration of cART did not correlate with lung function in earlier studies, it is likely that very early initiation will limit development of CLD.[26] Despite the limitations in our study, such as no control group and a non-random sample with a referral bias, we provide data on HIV-related CLD in children, emphasising the ubiquity of poor lung function, irreversible in the majority (82%) of children in our study. The strength of this study is the use of an objectively assessed outcome measure in multivariate analyses, viz. the FEV1. We further identified clinical signs associated with poor lung function.

Conclusion

We documented poor, often irreversible lung function in HIV-infected children evaluated for CLD. Easily assessed clinical signs, i.e. respiratory rate, hyperinflation and pigmented skin lesions, should alert clinicians to considering CLD in HIV-infected children and adolescents. Acknowledgements. The authors are thankful for the parents and their children who agreed to participate in this study. We thank Mrs Beulah Hill for coordinating the project and Emeritus Prof. William Pick for reviewing the manuscript. We are also grateful to the Tygerberg Children’s Hospital and KID-CRU, where the project was conducted.

References 1. UNAIDS. Global Report UNAIDS Report on the Global AIDS Epidemic 2010. Geneva: UNAIDS, 2010.

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2. Steinbrook R. The AIDS epidemic in 2004. N Engl J Med 2004;351(2):115-117. [http://dx.doi.org/10.1056/NEJMp048156] 3. National Department of Health South Africa. Guidelines for the Management of HIV in Children. 2010. 2nd ed. http://www. sahivsoc.org/upload/documents/Guidelines_for_Management_of_ HIV in_Children_2010.pdf (accessed 16 February 2014). 4. Graham SM, Gibb DM. HIV disease and respiratory infection in children. Br Med Bull 2002;61:133-150. 5. Ferrand RA, Desai SR, Hopkins C, et al. Chronic lung disease in adolescents with delayed diagnosis of vertically acquired HIV infection. Clin Infect Dis 2012;55(1):145-152. [http://dx.doi.org/10.1093/cid/cis271] 6. Sheikh S, Madiraju K, Steiner P, Rao M. Bronchiectasis in pediatric AIDS. Chest 1997:112(5):1202-1207. 7. Jeena PM, Coovadia HM, Thula SA, Blythe D, Buckels NJ, Chetty R. Persistent and chronic lung disease in HIV-1 infected and uninfected African children. AIDS 1998;12(10):1185-1193. 8. Jeena PM, Coovadia HM, Hadley LG, Wiersma R, Grant H, Chrystal V. Lymph node biopsies in HIV-infected and non-infected children with persistent lung disease. Int J Tuberc Lung Dis 2000;4(2):139-146. 9. Sharland M, Gibb DM, Holland F. Respiratory morbidity from lymphocytic interstitial pneumonitis (LIP) in vertically acquired HIV infection. Arch Dis Child 1997;76(4):334-336. 10. Berdon WE, Mellins RB, Abramson SJ, Ruzal-Shapiro C. Pediatric HIV infection in its second decade: The changing pattern of lung involvement. Clinical, plain film, and computed tomographic findings. Radiol Clin North Am 1993;31(3):453-463. 11. Norton KI, Kattan M, Rao JS, et al. Chronic radiographic lung changes in children with vertically transmitted HIV-1 infection. Am J Roentgenol 2001;176(6):1553-1558. [http://dx.doi.org/10.2214/ajr.176.6.1761553] 12. Zar HJ. Chronic lung disease in human immunodeficiency virus (HIV) infected children. Pediatr Pulmonol 2008;43(1):1-10. [http://dx.doi.org/10.1002/ ppul.20676] 13. Graham SM, Coulter JB, Gilks CF. Pulmonary disease in HIV-infected African children. Int J Tuberc Lung Dis 2001;5(1):12-23. 14. Pitcher RD, Lombard C, Cotton MF, Beningfield SJ, Zar HJ. Clinical and immunological correlates of chest X-ray abnormalities in HIV-infected South African children with limited access to anti-retroviral therapy. Pediatr Pulmonol 2014;49(6):581-588. [http://dx.doi.org/10.1002/ppul.22840] 15. World Health Organization (WHO). Physical status: The use and interpretation of anthropometry: Report of a WHO Expert Committee. WHO Technical Report Series No. 854. Geneva: WHO, 1995. 16. Miller MR, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J 2005;26(2):319-338. [http://dx.doi.org/10.1183/09031936.05.00034805] 17. Polgar G, Promadhat V. Pulmonary function testing in children: Techniques and standards. Philadelphia: Saunders, 1971. 18. Harrison VC. Handbook of Paediatrics in Developing Countries. Cape Town: Oxford University Press, 2004. 19. Rylance J, Mwalukomo T, Rylance S, et al. Lung function and bronchodilator response in perinatally HIV-infected adolescents: Malawi. In: Programs and Abstracts of the 19th Conference on Retroviruses and Opportunistic Infections (CROI 2012). Seattle, 2012. 20. Berman DM, Mafut D, Djokic B, Scott G, Mitchell C. Risk factors for the development of bronchiectasis in HIV-infected children. Pediatr Pulmonol 2007;42(10):871-875. [http://dx.doi.org/10.1002/ppul.20668] 21. Weber HC, Gie RP, Cotton MF. Review: The challenge of chronic lung disease in HIV-infected children and adolescents. J Int AIDS Soc 2013;16:18633. [http://dx.doi.org/10.7448/IAS.16.1.18633] 22. Miller RF, Kaski JP, Hakim J, et al. Cardiac disease in adolescents with delayed diagnosis of vertically acquired HIV infection. Clin Infect Dis 2013;56(4):576582. [http://dx.doi.org/10.1093/cid/cis911] 23. Wananukul S, Deekajorndech T, Panchareon C, Thisyakorn U. Mucocutaneous findings in pediatric AIDS related to degree of immunosuppression. Pediatr Dermatol 2003;20(4):289-294. 24. Nnoruka EN, Chukwuka JC, Anisuiba B. Correlation of mucocutaneous manifestations of HIV/AIDS infection with CD4 counts and disease progression. Int J Dermatol 2007;46(Suppl 2):14-18. [http://dx.doi.org/10.1111/ j.1365-4632.2007.03349.x] 25. Baveewo S, Ssali F, Karamagi C, et al. Validation of World Health Organization HIV/AIDS clinical staging in predicting initiation of antiretroviral therapy and clinical predictors of low CD4 cell count in Uganda. Plos One 2011;6(5):e19089. [http://dx.doi.org/10.1371/journal.pone.0019089] 26. Cotton MF, Violari A, Otwombe K, et al. Early time-limited antiretroviral therapy versus deferred therapy in South African infants infected with HIV: Results from the children with HIV early antiretroviral (CHER) randomised trial. Lancet 2013;382:1555-1563. [http://dx.doi.org/10.1016/ S0140-6736(13)61409-9]

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Severe pneumonia in HIV-infected and exposed infants in a paediatric ICU J Cloete, MB ChB, MMed (Paed), DCH(SA), Dip HIV Man(SA); P Becker, PhD; R Masekela, MB BCh, FC Paed (SA), MMed (Paed), Dip Allergol (SA), Cert Pulm (Paed) (SA), PhD; A Pentz, MB ChB, DCH (SA), FC Paed (SA), MMed (Paed), Dip Allergol (SA), Cert Pulm (Paed) (SA); W Wijnant, FC Paed (SA), MMed (Paed), Dip Allergol (SA), Cert Pulm (Paed) (SA); R de Campos, FC Paed (SA), MMed (Paed), Dip Allergol (SA); O P Kitchin, MB BCh, FC Paed (SA), MMed (Paed), Dip Allergol (SA), Cert Pulm (Paed) (SA); R J Green, PhD, DSc Department of Paediatrics and Child Health, Steve Biko Academic Hospital, Pretoria, South Africa Corresponding author: J Cloete (jeane.cloete@up.ac.za) Background. Pneumocystis jiroveci pneumonia is still a common cause of severe disease in HIV-infected infants <5 months of age. Despite attention to the prevention of mother-to-child transmission programme in South Africa (SA), HIV testing remains incomplete and infants are still at risk. The management of Pneumocystis pneumonia requires ventilation strategies and combination antibiotics. Methods. A prospective but open intervention was performed on all HIV-exposed patients admitted with severe pneumonia to the paediatric intensive care unit (PICU) at Steve Biko Academic Hospital, SA, during a 3-year period from January 2009 to December 2011. All patients were treated with ampicillin, amikacin, co-trimoxazole, prednisone and intravenous gancilovir. Highly active antiretroviral therapy (HAART) was initiated in the PICU as soon as tuberculosis was excluded and HIV status confirmed with an HIV viral load (VL). Routine blood and tracheal specimens were cultured for bacteria and tested by direct fluorescent antigen testing for P. jiroveci. Cytomegalovirus (CMV) VL was tested. All infants were ventilated in a standard fashion and none were oscillated. Results. A total of 87 patients were admitted during the 3-year period. Of these, 29 patients were excluded from the study because they were HIV-unexposed. Ten patients died during the 3-year period. In a multivariate analysis of the presence or absence of P. jiroveci, HIV VL, CD4 count, timing of HAART initiation and CMV VL, no single factor was documented to influence mortality. Conclusion. Mortality from Pneumocystis pneumonia continues to decrease in this PICU. No single factor is responsible and yet all therapeutic strategies contribute to survival. A national policy and guideline is urgently required. S Afr J Child Health 2015;9(3):76-80. DOI:10.7196/SAJCH.7941

Within South Africa (SA) (as in many other countries), HIV infection is a significant cause of morbidity in women and their infants. In SA, 26% of pregnant women are HIV-infected, and in the absence of preven tive therapy there is a 15 - 30% risk of HIV infection in their infants.[1,2] Even children who are part of the prevention of motherto-child transmission (PMTCT) programme have an increased risk of HIV-related infection relative to those who are not exposed, although that risk is substantially reduced. Mortality in HIV-infected children results primarily from respiratory tract infections.[3,4] In children (especially HIV-infected children) with acute severe respiratory disease requiring endotracheal intubation and ventilation, a number of pathogens (including Pneumocystis jiroveci and cytomegalovirus (CMV)) have been isolated. (The term PCP (P. pneumonia) was retained when P. carinii was taxonomically renamed P. jiroveci). Although there has been considerable focus on P. jiroveci as a cause of mortality,[5] CMV infection has been reported to affect nearly 90% of HIV-exposed infants,[6] especially HIVexposed infants with severe pneumonia. Admitting HIV-infected infants with severe pneumonia to an intensive care unit (ICU) in a resource-limited setting has created a number of ethical dilemmas for paediatricians, which have been accentuated by the historically poor outcome for these patients and the pressure on scarce resources.[7] However, previous reports have suggested that severe pneumonia can now be successfully treated when the mode of ventilation and antibiotic therapy is appropriate for all pathogens that may be present.[8] The successful management of PCP requires careful attention to ventilation strategies, fluid restriction and multiple antibiotics.[9] 76

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Objective

To report on the progress in improving survival of HIV-exposed and -infected infants admitted to a PICU with respiratory failure and acute respiratory distress syndrome (ARDS), and to explore the relationship between therapeutic strategies (which have not changed since the previous study)[9] and patient outcomes. In addition, this follow-up study reports on the use of highly active antiretroviral treatment (HAART) initiated in the PICU.

Methods

All HIV-exposed infants admitted to the PICU at the Steve Biko Academic Hospital in Pretoria, SA, with respiratory failure were recruited into this study. Patients had to fit the diagnosis of ARDS as described by Bernard et al.,[8] the most important criterion being hypoxic acute lower respiratory tract infection with a partial pressure of oxygen in mmHg over fraction of inspired oxygen (P/F) ratio of <200. Each infant was ventilated using a strategy of high positive end expiratory pressure (PEEP) of 10 - 15 cm of water, a tidal volume of 6 - 8 mL/kg and a positive inspiratory pressure (PIP) not exceeding 30 cm of water. Tidal volume was read from the ventilator display despite limitations of this technique.[10,11] None of the infants was offered high-frequency oscillation ventilation. Total fluid intake was restricted to 60 - 80 mL/kg/day and delivered medication was specifically included in the calculation of total fluid volume. This prospective study of all consecutive admissions meeting the inclusion criteria was conducted between January 2009 and December 2011. Each child had a number of investigations performed on admission, and airway specimens were collected within 2 hours of endotracheal intubation. Non-bronchoscopic broncho-

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ARTICLE alveolar lavage (NBBAL) specimens were collected for the following: P. jirovecii direct fluorescent antigen detection; bacterial microscopy, culture and sensitivity (MC&S); viral immunofluorescent assay (IFA) testing using the Light Diagnostics kit (Millipore-Chemicon, USA); and tuberculosis (TB) auramine staining and MC&S (Aerospray Automatic Stainer, Wescor ELiTech Group, France). Blood testing was conducted for white cell count (conducted using the automated haematology analyser Advia 2120, Siemens Diagnostics, SA), C-reactive protein (CRP) (measured using an immunoturbidometric reaction; Beckman Coulter Synchron LX20 PRO, Beckman Coulter Incorporated, USA), and CMV viral load (VL) polymerase chain reaction (PCR) (determined using a Toga lab on Cobas Amplicor instrument, Roche Diagnostics, Switzerland). An HIV DNA PCR was carried out by means of an Amplicor HIV-1 DNA test, version 1.5 (Roche Diagnostics). A peripheral blood volume of 2 mL was collected for blood culture after careful cleansing of the arm. Blood

was immediately injected into relevant blood culture bottles. Blood cultures positive for growth were plated onto agar and sensitivity was measured using a Kirby-Bauer technique (Bactec 9240, Becton Dickinson, USA). Each infant was treated at presentation with trimethoprimsulphamethoxazole (20 mg/kg/day of the trimethoprim component and 100 mg/kg/day of the sulphamethoxazole component) and oral steroids (1 - 2 mg/kg/day). Ampicillin and amikacin were routinely added at the time of admission and administered for 5 days unless a resistant organism was cultured, in which case appropriate antibiotics were administered; this is in accordance with the national guideline, which is based on the common organisms cultured in HIV-infected patients presenting with pneumonia. [12] These initial antibacterial antibiotics were changed to meropenem if the patient deteriorated after 48 hours of admission in order to treat the possibility of more resistant hospital-acquired organisms. Trimethoprim-sulphameth

Table 1. Pathogens isolated from blood culture, non-broncheolar lavage and viral isolates Culture Blood

NBBAL, bacterial and fungal

Survivors (n=43)

Non-survivors (n=10)

14 positive blood cultures (25.4%)

4 positive blood cultures (40%)

Organisms cultured

Coagulase-negative Staphylococcus spp.

Coagulase-negative Staphylococcus spp. and Enterococcus faecium together

E. faecium

Streptococcus pneumonia

S. hominis

Pseudomonas aeruginosa

Micrococcus spp.

Micrococcus and Bacillus spp. together

Klebsiella pneumoniae

16 positive cultures (37.2%)

3 positive cultures (30%)

Organisms cultured

Candida parapsylosis only

C. albicans with ESBL-producing Klebsiella spp.

C. albicans

ESBL K. pneumoniae

Only organism isolated

K. pneumoniae

Multiple organisms with ESBL K. pneumoniae and A. baumanii

ESBL K. pneumoniae (one mixed, one included)

Mycobacterium tuberculosis

K. pneumonia

Cultured mixed with Escherichia coli E. coli

1 2

Mixed with Klebsiella spp.

Streptococcus pneumoniae

4 positive cultures (8%) Viral isolates

2 positive cultures (20%)

Viral pathogens isolated

Parainfluenza 3 (one patient also had TB)

Respiratory syncitial virus (patient had C. albicans with ESBL Klebsiella spp. also isolated on sputum and negative blood culture)

Influenza A (patient also had positive S. pneumoniae blood culture and multiple organisms cultured on NBBAL)

Adenovirus

ESBL = extended spectrum beta lactamase producing; NBBAL = non-bronchoscopic broncho-alveolar lavage.

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ARTICLE oxazole was continued for 21 days and oral steroids for 14 days. In addition to these therapy standards, all children received intravenous ganciclovir (10 mg/kg/day). There are currently no guidelines on what constitutes CMV disease in the setting of CMV viral isolation. For the purposes of this study, CMV infection status was defined as follows: CMV disease: CMV VL >10 000 copies/mL (log>4); CMV infection: CMV VL 0.1 - 10 000 copies/mL (log–1 to log4) and CMV-uninfected: CMV VL negative. The value of 10 000 copies/mL was extrapolated from previous studies[13-15] and should be used together with clinical, radiological and laboratory support for CMV disease. PCR holds promise as an alternative diagnostic method.[16] Ganciclovir was continued until either CMV VL was <10 000 copies/mL or for 3 weeks after the onset of triple antiretroviral treatment (ART). Finally, HAART comprising lamuvidine, abacavir and lopinivir/ritonavir combination was initiated in the PICU as soon as TB was excluded and HIV status was confirmed with an HIV VL (RNA replication and amplification RT 2000 (Argos Therapeutics, USA). Approval to conduct the study was obtained from the Health Sciences Research Ethics Committee of the University of Pretoria and written informed consent was obtained from each parent with the help of a qualified PICU-trained nursing practitioner. In the case of infants who died, permission for postmortem examination was requested from each parent.

l axis, but four patients were on HAART at the time of entry to the study. The mean weight for age of the study population was 4.6 kg (z-score = –2.7), which is moderately underweight for age. All study children were HIV-exposed; 53 (96%) were HIV-infected with a positive HIV DNA PCR, while 2 (4%) were HIV-uninfected. Ten children (18%) died. Fifteen (27%) had P. jirovecii identified from an NBBAL specimen. Thirty-five (63%) children had a positive CMV VL, while 20 (27% of the total study group) had a CMV VL in the range determined as CMV disease. The most important outcome in this study was deemed to be survival and therefore discharge from the PICU. Each parameter or laboratory variable that might have reflected an infection on admission was analysed for prediction of mortality. Blood cultures were positive for bacterial organisms in 4 (40%) and 14 (25.4%) (p=0.5) of non-survivors and survivors, respectively. Other pathogens cultured on blood culture, and NBBAL bacterial, viral and fungal cultures are indicated in Table 1. These bacterial cultures

and viral isolates, together with neutropenia (11.1%) and elevated CRP (15.9%) were not contributors to mortality (p=0.508, p=1.000, p=0.256 and p=0.685, respectively). In a multivariate analysis of the presence or absence of P. jirovecii, HIV VL, CD4 count, timing of HIV treatment initiation and CMV VL, no single factor was documented to influence mortality. Included into the multivariate logistic regression, based on a 0.15 level of significance, were CMV status (p=0.174), CD4 percentage (p=0.887) and TB identified (p=0.177). Positive identification of P. jirovecii per se did not predict mortality (p=0.419). There was no relationship between time to initiation of HAART and survival or death (p=0.779). Five cases of immune reconstitution with CMV disease and one with TB occurred in the children initiated on HAART while in PICU (Table 2).

Discussion

Within a setting of HIV disease, mortality from respiratory failure in HIV-infected 4 excluded missing records/data

33 excluded 29 excluded HIV-unexposed

88 infants admitted to PICU with severe pneumonia

10 died 55 infants HIV-exposed

Statistical methodology

The associations of mortality with individual exposure variables, on an ordinal scale, were assessed using Pearson’s χ2 test and confirmed using Fisher’s exact test; for those exposure variables on a continuous scale, a Student two-sample t-test was employed and confirmed using Wilcox’s rank sum test. Testing was done at the 0.05 level of significance, and those exposure variables that were significant at the liberal 0.15 level of significance were included into the multivariate logistic regression analysis. Stata 10 (eStataCorp LP, USA) was used for computations.

2 HIV-exposed but HIV PCR-negative (4%)

43 survived

All survived

Fig. 1. Inclusion and exclusion criteria. 4 infants already on HAART

4 died 53 patients HIV-positive

Results

A total of 88 infants with pneumonia, respiratory failure and ARDS were admitted during the study period. Four were excluded because data were missing and 29 were excluded because they were HIV-unexposed. Therefore, a total of 55 infants qualified for final analysis (Fig. 1). The mean age was 3.7 (range 2 - 9, median 3) months. None of the infants in this study had received PCP (trimethoprim-sulphamethoxazole) prophy

53 HIV PCR-positive (96%)

29 HIV-positive infants initiated on HAART in PICU

25 survived

6 died 24 infants not initiated on HAART

Fig. 2. HAART initiation in infants in PICU.

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18 survived

ARTICLE Table 2. The profile of patients in whom immune reconstitution occurred

Patient number

Age (months)

Death in PICU

Death in ward

Days ventilated

PCP IFA

CMV VL (log) before initiation of HAART

CMV VL (log) after initiation of HAART

TB sputum culture

7.23

Negative

LDL

3.63

Negative

3.23

Negative

3.99

5.38

Negative

1.95

Yes

Negative

5.46

5.55

Negative

2.27

Negative

5.04

5.38

Negative

3.12

Yes

Positive

3.71

5.83

Negative

3.62

Positive

3.72

LDL

Positive (after 1 week)

LDL = lower than detectable limits.

and HIV-exposed infants was 18%. This is lower than in the study reported for the preceding 2-year period.[9] This is believed to be a result of the continued attention to management strategies in these infants. The only additional management tool that was added in subsequent years was early introduction of HAART in the PICU. This addition would probably add benefit to survival, but this study was not able to explore that effect as all children received it. However, because of logistical issues, not all children received their HAART at the same time during their stay. Analysis of the timing of onset of this therapy, however, did not reveal significant benefit between early and late initiation. If it is considered that mortality often occurs early, this may lead to the conclusion that HAART does not confer benefit. It certainly, however, does not impair survival. Unlike the previous study from this centre,[9] no specific factor was now shown to be associated with mortality. Two reasons for this phenomenon are proposed: firstly, overall mortality is now so low that the number of patients in identified risk groups is small; secondly it seems likely that the overall management plan, with all the selected interventions, is now contributing, in unison, to survival. The survival disadvantage from CMV disease identified in the previous study[9] is now lost. This is encouraging, as this centre has persevered with the use of early ganciclovir despite initial suggestions of failure of this form of therapy to halt mortality.[8] The important lesson in PCP, a severe and often fatal condition, is that the results of a single study should not be used to make life-saving or life-ending decisions. In addition to documentation of improved survival from PCP, it should be noted that the mode of ventilation had not changed in this PICU. No infant received ventilation by means of high-frequency oscillation (HFO). This is an important feature of this study, since it has been suggested that PCP with ARDS requires HFO. Survival despite the absence of this strategy has cost implications for a developing country and should be factored into national policy. Until such time as identification, prevention and prophylaxis of HIV in pregnancy is secure in the developing world, it seems prudent to develop a national or international guideline and policy on management of this condition. Currently, pneumonia guidelines are quiet on this issue. A case fatality rate of 18% has been achieved through a meticulous approach to management of the interaction between the host and infection in infants with respiratory failure. This has been demonstrated previously.[9] In 2004, Cooper et al.[17] documented that HIV-infected children admitted to a PICU in London had a 38% mortality when every effort was made to treat such children. The actual mortality of these infants beyond the PICU into the first year of life is a subject of an ongoing study. However, all the patients in the Cooper et al.[17] study who were HIV-infected received ART early 79

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in the course of their disease, and survival to 1 year of age appears to be better than reported in previous studies.[18] It appears that in exchange for improved survival, the use of HAART may be unmasking immune reconstitution inflammatory syndrome with emergence of infectious diseases. However, those conditions are treatable and children survive them.

Study limitations

The major limitation of our study was the definition of CMV disease. Clearly, use of a blood measure of VL does not imply pulmonary disease. This fact has not escaped our attention, but, short of lung biopsy, actual proof of CMV infection has been difficult in previous studies. In addition, the close correlation between CMV VL and mortality must suggest that this test is identifying some disease process. Exactly what that disease is, is unclear from our study. Some additional limitations include failure to identify fully all potential pathogens through PCR and culture techniques. Such testing would enhance the diagnostic yield in our study, but would, of course, not have changed our therapeutic strategy as all organisms, with the exception of TB, were empirically treated. An attempt was also made to get postmortem biopsies on the 10 deaths, but permission was denied by all the parents. This would have given us the opportunity to observe the histology of the lungs in order to determine whether fibrosis was the end-stage pathology of patients with this form of ARDS.

Conclusion

Respiratory failure in infants who are HIV-exposed or -infected has more than one aetiology, and mortality can be improved through multiple treatment modalities. Perseverance with ventilation and multiple antibiotic agents is highly successful for curing a previously fatal respiratory disease. The value of early HAART is difficult to assess but may be contributing to improved survival. At the very least it is not detrimental. It remains pertinent to point out that effective antenatal care with diagnosis and appropriate therapy of infected mothers can virtually eliminate the secondary problems of HIV infection in young children. References 1. National Department of Health South Africa Policy and Guidelines of Implementing PMTCT Programme. 2008 http://www.doh.gov.za/docs/ policy-f.htmL (accessed 1 April 2011). 2. De Cock KM, Fowler MG, Mercier E, et al. Prevention of mother-to-child HIV transmission in resource-poor countries: Translating research into policy and practice. JAMA 2000;283(9):1175-1182. 3. Graham SM, Gibb DM. HIV disease and respiratory tract infection in children. Br Med Bull 2002;61:133-150.

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ARTICLE 4. Jeena P. The role of HIV on respiratory tract infection in sub-Saharan Africa. Int Tuberc Lung Dis 2005;9(7):708-715. 5. Stringer JR, Beard CB, Miller RF, Wakefield AE. A new name (Pneumocystis jiroveci) for pneumocystis from humans. Emerg Infect Dis 2002;8(9):891-896. [http://dx.doi.org/10.3201/eid0809.020096] 6. Slyker JA, Lohman-Payne BL, John-Stewart GC, et al. Acute cytomegalovirus infection in Kenyan HIV-infected infants. AIDS 2009;23(16):2173-2181. [http://dx.doi.org/10.1097/QAD.0b013e32833016e8] 7. Jeena MP, McNally LM, Stobie M, Coovadia HM, Adhikari MA, Petros AJ. Challenges in the provision of ICU services to HIV infected children in resource poor settings: A South African case study. J Med Ethics 2005;31(4):226-230. [http://dx.doi.org/10.1136/jme.2003.004010] 8. Bernard GR, Artiqas A, Brigham AL, et al. Report of the American-European consensus conference on ARDS: Definitions, mechanisms, relevant outcomes and clinical trial coordination. The Consensus Committee. Inten Care Med 1994;20(3):225-232. 9. Kitchin O, Masekela R, Moodley T, et al. Outcome of HIV exposed and infected children admitted to a pediatric intensive care unit for respiratory failure. Pediatr Crit Care Med 2012;13(5):516-519. [http://dx.doi.org/10.1097/PCC.0b013e31824ea143] 10. Heulitt MJ, Thurman TL, Holt SJ, et al. Reliability of displayed tidal volume in infants and children during dual-controlled ventilation. Pediatr Crit Care Med 2009;10(6):661-667. [http://dx.doi.org/ 10.1097/PCC.0b013e3181bb2b2b] 11. Castle RA, Dunne CJ, Mok Q, et al. Accuracy of displayed values of tidal volume in the pediatric intensive care unit. Crit Care Med 2002;30(11):25662574. [http://dx.doi.org/10.1097/01.CCM.0000034675.10801.2A]

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12. Zar HJ, Jeena P, Argent A, et al. Diagnosis and management of communityacquired pneumonia in childhood: South African Thoracic Society Guidelines. S Afr Med J 2005;95(12 pt 2):977-990. 13. Boeckh M, Boivin G. Quantitation of cytomegalovirus: Methodologic aspects and clinical applications. Clin Microbial Rev 1998;11(3):533-554. 14. Hsiao NY, Zampoli M, Morrow B, Zar HJ, Hardie D. Cytomegalovirus viraemia in HIV exposed and infected infants: Prevalence and clinical utility for diagnosing CMV pneumonia. J Clin Virol 2013;58(1):74-78. [http://dx.doi.org/10.1016/j. jcv.2013.05.002] 15. Zampoli M, Morrow B, Hsiao M, Whitelaw A, Zar HJ. Prevalence and outcome of cytomegalovirus-associated pneumonia in relation to human immunodeficiency virus. Pediatr Infect Dis J 2011;30(5):413-417. [http:// dx.doi.org/10.1097/INF.0b013e3182065197] 16. Bransaeter AB, Holberg-Petersen M, Jeansson S, et al. CMV quantitaitive PCR in the diagnosis of CMV disease in patients with HIV-infection: A retrospective autopsy based study. BMC Infect Dis 2007;7:127-134. [http:// dx.doi.org/10.1186/1471-2334-7-127] 17. Cooper S, Lyall H, Walters S, et al. Children with human immunodeficiency virus admitted to a paediatric intensive care unit in the United Kingdom over a 10-year period. Intensive Care Med 2004;30(1):113-118. [http://dx.doi. org/10.1007/s00134-003-2074-7] 18. Cowburn C, Hatherill M, Eley B, et al. Short-term mortality and implementation of antiretroviral treatment for critically ill HIV-infected children in a developing country. Arch Dis Child 2007;92(3):234-241. [http:// dx.doi.org/10.1136/adc.2005.074856]

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Parents’ journey into the world of autism A Alli,1 BA (Speech Pathology and Audiology); S Abdoola,2 MA (Speech Pathology and Audiology); A Mupawose,2 PhD (Speech Pathology and Audiology) 1 2

Johannesburg Hospital School for Children with Autism, Johannesburg, South Africa Department of Speech Pathology and Audiology, Faculty of Humanities, University of the Witwatersrand, Johannesburg, South Africa

Corresponding author: A Alli (aaa3alli@gmail.com) Background. Autism Spectrum Disorder (ASD) is a developmental disability that results in an impairment in an individual’s social interaction and communication, as well as restricted, repetitive and stereotyped patterns of behaviour. Children with ASD display difficulties in the areas of social as well as communicative behaviour. Parents, caregivers and family members are the main communication partners of children with ASD. Living with a child with ASD can result in changes within a family system. Objective. To describe the challenges and experiences faced by families in their interaction with their child with ASD, caregiver coping strategies and the success of these strategies, and the generalisation and carryover of therapeutic strategies provided by a speech language pathologist (SLP). Methods. A qualitative descriptive research design was selected to explore the objectives of the study. Ten participants were recruited; all participants were parents of a child with ASD attending Learners with Special Educational Needs School in Gauteng, South Africa. Data were collected through a semistructured face-to-face interview survey comprising open- and closed-ended questions, and were analysed using thematic content analysis. Results. The results revealed five main themes, namely communicative challenges, family experiences, communicative coping strategies, speech and language therapy services and strategies provided by the SLPs. Communicative challenges were experienced by parents of one child with ASD. The communication and behaviour of children with ASD were found to affect the daily functioning of the family. The majority of parents reported not learning a new mode of communication, but rather adapting and adjusting to the communication of their child. Communicative coping strategies were required for novel social settings. There were mixed responses with respect to parent’s abilities to access and learn new communicative coping strategies. Speech and language therapy assisted in improving the child’s communication skills, while strategies provided by SLPs were explained to be effective even though generalisation of strategies was limited. Conclusion. This study concluded that parents and children with ASD experience challenges in communication and interaction. The family systems approach as well as the World Health Organization’s International Classification of Impairments, Disabilities and Handicaps are two functional frameworks that can assist SLPs to provide intervention to children with ASD. S Afr J Child Health 2015;9(3)81-84. DOI:10.7196/SAJCH.7942

Autism Spectrum Disorder (ASD) manifests as a qualitative impairment in an individual’s social interaction and communication, as well as restricted, repetitive and stereotyped patterns of behaviour.[1] The core characteristics found in a child with ASD include difficulties in social communication, language and related cognitive skills, and behaviour, as well as emotional regulation.[2] Children with ASD can present with difficulties in all five aspects of language (phonology, semantics, syntax, morphology and pragmatic); these difficulties vary according to the particular diagnosis of each child. It is generally agreed upon that whatever the diagnosis of a child with ASD, deficits in pragmatic skills and theory of mind are always present. These social communication deficits of a child with ASD may create a limitation in social experience, contributing to impaired development and learning, and challenging behaviours. Thus, children with ASD require a clear and effective mode of communication.[3] Speech language pathologists (SLPs) play an important role in enhancing a child’s daily language skills, but therapy needs to extend beyond the therapy environment as a means of improving quality of life and daily functioning. Disabilities with a social component (such as ASD) are transactional; this implies that the effect of the language deficit does not only affect the child but the communication partners as well.[4] Communication partners are required to modify their interactive style and the environment in order to ensure successful communication. [5] Consequently, SLPs should recognise the significance of family involvement in the therapy process. Together, the SLP and family members should assess and monitor the effectiveness of intervention 81

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for the child with ASD;[5] because programmes that include parents/ caregivers prove to be effective with the involvement of SLPs.[6] The study conducted was undergirded by two theoretical frame works, namely the family systems approach and the International Classification of Functioning, Disability and Health (ICF) for children. The family systems approach is based on the notion that an individual’s behaviour should be viewed and addressed within the context of the family.[7] The family undergoes changes and development over time, through which they are able to achieve a state of homeostasis.[8] Children with ASD are faced with developmental challenges that affect parental and family functioning, resulting in significant stress for all family members.[9] ICF is an early classification scheme introduced by the World Health Organization; it defines disability under three components, namely impairment, activity limitations and participation restriction.[10] The ICF allows for individuals to be classified according to health domains (hearing, talking and memory) as well as health-related domains (education and social interaction).[10] The ICF classification allows for ASD to be classified as a disability, owing to the associated language impairment and limitation in activity participation. The ICF presents factors that result in functional limitations as well as factors that may enhance optimum functioning, thereby guiding SLPs to help children with language impairment to improve their daily functioning in terms of language, communication and interaction.[11] The challenges experienced by parents/caregivers in raising a child with ASD have been documented mainly in England, North America and Australia.[12] In addition, research regarding the communicative

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ARTICLE difficulties of children with ASD has been conducted;[13] however, there is a paucity of information within the South African (SA) context regarding the experiences and challenges that parents face when communicating with their autistic child. SA is culture rich, allowing for diversity in the experiences of parents/caregivers; therefore, research regarding families who are affected by ASD is essential.

Objective

The objective of this study was to explore and describe the communicative experiences and challenges of parents/caregivers of a child with ASD within the SA context. An additional objective was to describe caregiver coping strategies and the success of these strategies in families with children with ASD, while determining the carryover of therapy strategies.

Methods

A descriptive research design was utilised. Non-probability pur posive sampling was used to recruit ten participants. The sample comprised parents whose children were currently attending Learners with Special Educational Needs (LSEN) School in Gauteng Province, SA. An inclusion criterion was formulated to establish the eligibility of the participants in the study. A semistructured interview survey comprising open- and closed-ended questions was used. Written consent was provided by the Gauteng Department of Education as well as the principal of LSEN School. Ethical clearance was granted by the University of the Witwatersrand Human Research Ethics Committee (H13/03/09). All participants in the study were fully informed about the nature of the study. Participants provided written consent for participating in the interview as well as for the recording of the interview. Interviews were transcribed and analysed.

Results

Description of participants

All participants were parents of children with ASD. Nine participants were female (mothers) and one was male (father). Nine of the participants had sons and one had a daughter. The average age of participants was 41.4 years. All parents reported having only one child with ASD. Seven participants were black, two were Indian, and one was white. The average current age of children in question in the study was 11.8 years. The average age of diagnosis was reported to be 2.7 years. At the time of the study, all children had access to speech and language intervention through school therapists. Thematic content analysis revealed five main themes, namely:

Communicative challenges (subthemes: parent challenges and communicative challenges)

All respondents indicated experiencing challenges in both the receptive and expressive language domains of communication. Four participants reported challenges in understanding the signs utilised by their child. Five parents indicated having difficulty in providing instructions and commenting about items or topics that were not present in the environment of the child. Due to the lack of social interaction, one participant reported challenges in receiving any form of communication from her son. One participant further explained challenges in understanding her child due to articulation difficulties. From the subtheme communicative challenges, it was found that five participants described communication in a social setting as challenging owing to the change of environment. Six parents reported that communicating in a social setting was more challenging than in the home environment, where factors can be controlled and the environment remains familiar. Four respondents further pointed out that communication with a stranger proved to be challenging, as people demonstrated difficulty in understanding the behaviour and communication of a child with ASD; one parent attributed this finding to the lack of education of the public regarding ASD. 82

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Family experiences (subthemes: daily functioning with family and communication with siblings)

Four participants reported that having a child with ASD had influenced the daily functioning of their family. Participants indicated that they were required to adjust their manner of communication as well as their daily activities. Five participants reported no difference in their daily functioning. All participants indicated that the child with ASD was unable to participate in family discussions. For the theme communication with siblings, two participants reported that their child with ASD could not communicate and interact with their sibling. Six participants’ responses implied that siblings were able to communicate through signing or verbal means; however, their interactions through play and communication were limited. It was found that older siblings had a better understanding of ASD.

Communicative coping strategies (subthemes: learning a new mode of communication; coping strategies adopted in a home setting v. the social setting; and access to communication strategies)

Three participants stated the need to learn a new mode of communication as a coping mechanism to communicate with their child. One parent reported learning the Picture Exchange Communication System (PECS) during her stay in the USA; this participant further reported abolishing the PECS system owing to it being time consuming and restrictive in a natural setting. The seven remaining participants reported not learning a new mode of communication; participants described adjusting and adapting to the communication of their ASD child as needed. In terms of coping strategies, six participants were required to adopt new strategies in a social setting in comparison with their home setting. Two parents specified that owing to the pressures of a social setting, they were required to be protective and supportive towards their child, whereas their child was expected to demonstrate more independence in a home setting. Settings that included individuals who were familiar to the child and who possessed knowledge regarding ASD proved to be less stressful. Four parents expressed negative responses regarding access to information regarding communication strategies in ASD. However, the remaining participants reported that they were able to find information through the LSEN School and networks such as Autism SA, Ernie Els Centre and social media groups.

Speech and language therapy services (subtheme: improvement in speech and communication skills with therapy)

All parents believed that speech and language therapy resulted in an improvement in their child’s communicative skills. Parents reported noting improvements in their child’s verbal output, mean length utterances, signing and vocalisations.

Communication strategies provided by the SLP (subthemes: type of communicative strategies provided and effectiveness of the strategy provided)

Eight parents reported receiving communicative strategies through meetings and workshops held by teachers and SLPs based at the school. Two participants reported not receiving communicative strategies from the SLP (reasons were not provided). From the responses, it was noted that parents were provided with strategies associated with the objectives of and activities conducted in therapy sessions. Parents explained receiving strategies in terms of encouraging vocalisations, the use of PECS and communication through Mekaton signing. It was further noted that the same strategies were provided for both home and social settings. Seven respondents indicated that they were pleased with the strategies provided by the SLP; however, carryover to the home environment was limited.

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ARTICLE Discussion

The communication challenges of children with ASD found in this study are an example of the manner in which language impairment affects a child’s activity limitations and participation restrictions. These communication challenges are related to the ICF framework; language impairments are viewed as a disability in the ICF frame work.[11] The findings of this study should be considered in conjunction with findings that indicate that children with ASD are faced with developmental challenges that affect family functioning. [9] The study demonstrated the importance of understanding the family systems approach in working with children with ASD. Having a child with ASD affects family functioning in areas such as family events, planning of activities (as parents are required to plan ahead), and the marital relationship.[14] The study also demonstrated findings with regard to sibling communication. Understanding the sibling relationship in the ASD population is important, as siblings become the main caregiver of their ASD brother/sister in cases where parents are no longer able to provide care.[15] Previous studies have reported that families with a child with ASD adopt coping strategies such as distancing, escape and redefining personal goals as well as family priorities.[16] These findings were dissimilar to those of this research study, which described the communicative coping strategies which parents have adopted. Parents reported the need to adopt a new mode of communication, such as PECS, in order to communicate with their child. An SA study conducted by Travis and Geiger[17] indicated PECS to be a suitable system for parents, educators and children with ASD in terms of communicative functions such as requesting, which provided an explanation for the use of PECS by one participant in this study. Coping strategies were reported to be more significant in social settings compared with the home environment. Another study[18] reported that parents found themselves inadequate in dealing with the behaviours presented by the child with ASD, making social outings difficult for families. Participants explained that the lack of understanding regarding the ASD by the community resulted in families having limited contact with the community. Speech and language services form an integral part in the remediation of a child with ASD. It is recommended that all children with ASD receive speech and language services owing to the nature of their social communication impairment.[19] Children with ASD are required to adopt various strategies to communicate. They may utilise PECS, sign language, gestures or a mixed system as a means of communication.[20] This was noted in the responses parents provided with regard to the areas of improvement that they had noted since their child had begun attending speech and language therapy. From this research study, it was found that improvement was noted in speech, language and interactive skills following speech and language intervention. However: ‘the impact of speech-language services on language outcomes for individuals with ASD has not been systematically investigated.’[16] The current study revealed that eight parents were receiving communication strategies (from the SLP) that enabled communication and interaction with their child. This finding is encouraging, as it is essential that SLPs build partnerships with families to develop learning opportunities, provide information, teach strategies and offer feedback.[21]

Theoretical/clinical implications of the study

In the current study, it was found that a child with ASD influenced the daily functioning of the immediate family members. The study indicated that the family system was influenced by a change brought about by one individual; the family was required to reach a new state of homeostasis. This finding implies the importance of considering the family system approach during the process of intervention. In addition, the study revealed the manner in which a disability such as ASD affects not only anatomical structures of the child but also 83

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activity limitations and participation restrictions. This was noted in the restrictive communicative and interactive skills that the child with ASD displayed. The ICF framework aspires to improve the quality of life of individuals with a disability.[11] The improvement in a child’s quality of life is an important reflection that SLPs should consider when providing intervention. The ICF can be used as a framework during the intervention process, as its objective is to assist SLPs in understanding the factors that maintain functional limitations and those that facilitate optimal functioning. As a result, SLPs may help children with language impairments to improve functioning in their everyday life.[11] This study discovered that SLPs are providing communicative strategies for parents; however, strategies could not be generalised to all settings. This finding demonstrates the importance of providing home-based strategies that serve as a functional and realistic resource that can be utilised by parents in all settings. Additional clinical implications included the importance of considering the communication and interactive challenges faced by both the parent and the child with ASD. The family systems approach and the ICF are beneficial theoretical frameworks that SLPs should consider during the rehabilitation process of clients.

Study limitations

The study involved a small sample size, which restricts the generalisation of findings to the SA population. The study did not include a comparison group of children who did not have access to intervention; therefore it cannot be concluded that improvement in the speech and language skills of the children in question (reported by parents) is attributed to SLP services. Participants were recruited from only one school, therefore responses were limited to therapy provided by the SLP present at the school. In addition, the social and economic demographics of participants in the study were not gathered; therefore findings cannot be generalised to all children with ASD within the SA context. This study involved an unequal number of races; as a result, it cannot be concluded that ethnic factors did not play a role in the responses provided. The study entailed a semistructured survey with specific questions chosen by the researcher; consequently, salient issues may have been neglected.

Recommendations

Future research can expand on the interviews conducted in this study by using an explorative descriptive design with a larger sample size of participants from a variety of social and economic settings. This study involved participants who had access to SLP services within the school setting; however, future studies should consider children who do not have access to these services. As SA has a culturally diverse population, future research could further investigate the effect of culture on challenges and experiences of parents of a child with ASD. Another study could investigate the challenges and experiences that SLPs face in the therapy setting.

Conclusion

The information derived from this study contributed to the limited information available pertaining to speech and language therapy services for children with ASD within the SA context. Furthermore, it provided an understanding of the challenges and experiences of parents of a child with ASD. Insight into the communication skills and needs of children with ASD without causing direct harm was gained. Children spend a large proportion of their time with their parents, who are their frequent communication partners. Parents encompass valuable information and insight regarding the difficulties and skills of their child. Professionals working with children with ASD should be made aware of the significant role parents play in their child’s progression. This study demonstrated the important role of parents as well as the role of beneficial frameworks, such as the

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ARTICLE family systems approach and the ICF. The results should contribute to the knowledge and clinical skills of professionals working to improve the quality of life of children with ASD. References 1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders IV, 2000.http://www.psychiatry.org/practice/dsm/2013 (accessed 7 July 2013). 2. American Speech-Language-Hearing Association. Practice Policy 2006 – Guidelines for Speech-language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders across the Lifespan. http://dx.doi. org/10.1044/policy.GL2006-00049 (accessed 13 July 2013). 3. Beukelman DR, Mirenda P. Augmentative and Alternative Communication: Management of Severe Communication Disorders in Children and Adults. 2nd ed. Baltimore: Paul H Brookes, 1998:75-108. 4. Wetherby AM, Prizant BM. Introduction to autism spectrum disorders. In: Wetherby AM, Prizant BM, eds. Autism Spectrum Disorders: A Transactional Developmental Perspective. Baltimore: Brookes, 2000:1-7. 5. American Speech-Language-Hearing Association. Technical report 2006 – Principles for Speech-language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders across the Lifespan, 2006. http:// dx.doi.org/10.1044/policy.TR2006-00143 (accessed 13 July 2013). 6. American Speech-Language-Hearing Association. Position Statement 2006 – Roles and Responsibilities of Speech-language Pathologists in Diagnosis, Assessment, and Treatment of Autism Spectrum Disorders across the Lifespan, 2006. [http://dx.doi.org/10.1044/policy.PS2006-00105] 7. Mirsalimi H, Perleberg SH, Stoval E, Kaslow NJ. Family psychotherapy. In: Weiner BI, ed. Handbook of Psychology: Clinical Psychology. Hoboken, USA: John Wiley & Sons, 2003:225-233. 8. McLead J. An Introduction to Counseling. 4th ed. Buckingham: Open University Press, 2003:98-105. 9. Roa PA, Beidel DC. The impact of children with high-functioning autism on parental stress, sibling adjustment, and family functioning. Behav Modif 2009;33(4):437-451. [http://dx.doi.org/10.1177/0145445509336427] 10. World Health Organization. International Classification of Functioning, Disability and Health (ICF), 2001. http://www.who.int/classifications/icf/en/ (accessed 2 July 2013).

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11. Dempsey L, Skarakis-Doyle E. Developmental language impairment through the lens of the ICF: An integrated account of children’s functioning. J Commun Disord 2010;43(5):424-437. [http://dx.doi.org/10.1016/j.jcomdis.2010.05.004] 12. Lainhardt JE. Psychiatric problems in individuals with autism, their primary caregivers and siblings. Int Rev Psychiatry 1999;11(4):278-298. 13. Wolraich M, Dworkin PH, Drotar DD, Perrin EC. Developmental-behavioural Pediatrics: Evidence and Practice. Philadelphia, USA: Mosby Inc., 2008:65-89. 14. Montes G, Halterman JS. Psychological functioning and coping among mothers of children with autism: A population-based study. Pediatr 2008;119(5):1040-1046. http://pediatrics.aappublications.org/content/119/5/e1040.abstract (accessed 10 July 2013). 15. Orsmond GI, Kuo H, Seltzer MM. Siblings of individuals with an autism spectrum disorder: Sibling relationships and wellbeing in adolescence and adulthood. Autism 2009;13(1):59-80. [http://dx.doi.org/10.1177/1362361308097119] 16. Sivberg, B. Family system and coping behaviors: A comparison between parents of children with autistic spectrum disorders and parents with nonautistic children. Autism 2001;6(4):397-409. [http://dx.doi.org/10.1177/13623 61302006004006] 17. Travis J, Geiger M. The effectiveness of the Picture Exchange Communication System (PECS) for children with autism spectrum disorder (ASD): A South African pilot study. Child Lang Teach Ther 2010;26(1):39-59. http://clt. sagepub.com/content/26/1/39 (accessed 11 November 2013). [http://dx.doi. org/10.1177/0265659009349971] 18. Higgins DJ, Bailey SR, Pearce JC. Factors associated with functioning style and coping strategies of families with a child with an autism spectrum disorder. Autism 2005;9(1):125-137. [http://dx.doi.org/10.1177/1362361305051403] 19. American Speech-Language and Hearing Association. ASHA Practice Policy 2006 – Knowledge and Skills Needed by Speech-language Pathologists for Diagnosis, Assessment, and Treatment for Autism Spectrum Disorders across the Lifespan. [http://dx.doi.org/10.1044/policy.KS2006-00075] 20. Paul R, Gilbert K. Development of language and communication. In: Hollander E, Kolvzen A, Coyle JT, eds. Textbook of Autism Spectrum Disorders. Arlington, USA: American Psychiatric Publishing Inc., 2010:147-159. 21. National Research Council (NRC). EBP Compendium: Summary of Clinical Practice Guideline 2010 – Educating Children with Autism. Washington, DC: National Academy Press, 2010. http://www.asha.org/Members/ebp/ compendium/guidelines/Educating-Children-with-Autism.htm (accessed 30 July 2013).

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Current practices around HIV disclosure to children on highly active antiretroviral therapy G D Naidoo,1 MB ChB, MMed (Paediatrics and Child Health), DCH (SA), FCPaed (SA); N H McKerrow,1,2 MB ChB, BA, DCH (SA), FCPaed (SA), MMed Paed, PG Dip Int Research Ethics Department of Paediatrics, Nelson Mandela School of Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa 2 KwaZulu-Natal Provincial Department of Health, Durban, South Africa 1

Corresponding author: G Naidoo (gitanya.naidoo@gmail.com)

Background. The introduction of antiretroviral therapy (ART) for children has resulted in survival into adolescence. This is associated with the challenge of disclosing HIV status to infected children. Objectives. To establish whether HIV disclosure had occurred, the process of disclosure or reasons for non-disclosure, and the effect of disclosure on the child’s understanding of their disease and adherence. Methods. Interviews were conducted with the caregivers of 100 HIV-positive children, aged 8 - 14 years, who were on ART for >1 year to determine if disclosure had occurred. Where disclosure had occurred, these children were interviewed. Results. Disclosure had occurred in only 27 patients. The age and gender of the caregiver and their relationship to the child did not influence the likelihood of disclosure. The educational level of the caregiver and the number of admissions of the child were both associated with disclosure. Disclosure did not improve adherence, as reflected by an increased CD4 count or reduced viral load. Conclusion. HIV disclosure to children on ART remains less than optimal despite the presence of both national and international guidelines. Caregivers cited fear on the part of the child and fear of being blamed for their illness as the main reasons that they do not disclose. Of the children who knew their status, 76.9% had already suspected that they had HIV. S Afr J Child Health 2015;9(3)85-88. DOI:10.7196/SAJCH.7957

South Africa (SA) remains the epicentre of the global HIV epidemic. The 2009 antenatal HIV seroprevalence survey[1] estimated an HIV prevalence of 29.4% in pregnant women, with an estimated 5.2 5.63 million HIV-infected adults and children in the country. The Human Sciences Research Council’s 2012 household survey[2] estimated an HIV prevalence of 2.4% in children between the ages of 2 and 14 years and 1.7% in children <5 years of age. This equates to 369 000 HIV-infected children, of whom 166 000 were on antiretrovirals (ARVs) (45.1%). Antiretroviral therapy (ART) is critical in the effective care and management of the HIV-infected individual. With the initiation and the increasing roll out of ART, HIV-infected children experience a less symptomatic early course, live longer and have a better quality of life.[3] The extensive use of ART has changed paediatric HIV infection into a chronic disease of childhood. The social difference between this and other chronic childhood diseases lies in the stigma associated with HIV infection. This frequently results in an emotional response from infected individuals upon disclosure of such a diagnosis. [4] As with other diseases, knowledge about the condition and treatment thereof is essential for understanding and accepting the diagnosis. One of the greatest psychosocial challenges that parents and caregivers of HIV-infected children face is disclosing HIV status to their children and enlisting the child’s cooperation in treatment programmes. HIV disclosure entails communication about a potentially life-threatening, stigmatised and transmissible illness, and many caregivers fear that such communication may create distress for the child.[5] Research on disclosure to children with cancer showed that prior to the 1970s, children were given little information regarding their 85

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condition and prognosis, as it was thought that they had limited understanding about the illness and required protection from the emo tional burdens faced by their parents. Recent advances support a more open and communicative approach to children with cancer in light of improved survival rates, increasing advocacy for children’s rights and children’s participation in the management of their disease.[6] In 1999, the American Academy of Pediatrics[7] released guidelines suggesting that adolescents should know their HIV status and that HIV disclosure should be considered for school-aged children. Local guidelines suggest that disclosure should be an ongoing, progressive process supported by parents and caregivers.[8] These guidelines suggest that disclosure should occur at an age-appropriate level, recognising the child’s cognitive and developmental level. It is suggested that partial disclosure occurs between the ages of 8 and 11 years, and full disclosure, assuming better understanding of the HIV disease and treatment options, between 11 and 14 years. Failure to achieve full disclosure by the early teens is associated with poor adherence, emotional difficulties, breakdown of trust and unwitting HIV transmission.[6]

Methods

The study was conducted at the Paediatric ART Clinic, Edendale Hospital, Pietermaritzburg. Participants for the study were recruited over a 2-week period in December 2013 during routine follow-up visits to the clinic. The caregivers of HIV-infected children aged 8 - 14 years who had completed at least 12 months of ARV treatment were enrolled in the study. Children to whom their HIV status had been disclosed were also enrolled in the study. Interviews were conducted in the interviewee’s home language, using standardised questionnaires specific to the caregiver or the

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ARTICLE child. Three different questionnaires were used. A questionnaire was designed for caregivers who had disclosed to assess when and how disclosure was conducted, and the response of the child to disclosure. A separate questionnaire was used to assess the reasons for non-disclosure by caregivers. Lastly, there was a questionnaire aimed at the children who were aware of their HIV status, to provide information regarding the child’s response to disclosure. Clinical records of all children, irrespective of disclosure, were reviewed with respect to their clinical, immunological and virological status. In children where disclosure was noted, a comparison of these parameters was done pre- and postdisclosure. Ethical approval for the study was obtained from the Biomedical Research Ethics Committee of the University of KwaZulu-Natal. Statistical analysis was undertaken with the assistance of the Discipline of Public Health Medicine, University of KwaZulu-Natal, using χ2, Student’s t-test or the Fisher’s exact test. A p-value of <0.05 was considered statistically significant.

Results

The caregivers of the first 100 children who met the criteria and consented to participate were enrolled in the study. Of these children, disclosure had occurred in 27 patients, while 73 were unaware of their HIV status. Characteristics of the caregiver are represented in Table 1. While most caregivers were female, there was a slightly higher number of males in the non-disclosure group; however, this was not statistically significant. The age range was broader in the non-disclosure group while the mean was less; however, this was not significant. The majority of caregivers knew their HIV status and the proportion of HIV-positive caregivers in the groups was similar. The data indicated that caregivers with either no formal education or only primary education were more likely to disclose than those with secondary education. The characteristics of the children who participated in the study are portrayed in Table 2. The age range was similar in both groups, and reflected the narrow age range of the selection criteria. The majority of children (77%) had been on ART for >5 years. A slightly higher percentage of children who were on treatment for <5 years were disclosed to than those on treatment for >5 years, i.e. 30% and 26%, respectively. Children who had more than five admissions to hospital were 33% (odds ratio 1.33) (p=0.03) more likely to have their status disclosed to them than children with one or two admissions. Table 3 provides information relating to the process of disclosure to children. Although the mean age of disclosure was 11.6 years, disclosure had occurred in 58% of children by the age of 10 years. In most instances (84.6%), the parent disclosed. In the majority of cases (72.0%), this was in response to the advice of a healthcare worker. Caregivers conducted just over half (55.6%) of these disclosures alone, while the remainder were assisted by the healthcare worker. At the time of disclosure, an equal number of children already knew their HIV status to those who were unaware of their diagnosis. On hearing their HIV status, 7.4% of the children were afraid. Every caregiver who had disclosed the HIV status to their child believed that their child had a right to know this status and was happy that they were aware of it. Caregivers who had not disclosed were questioned regarding their rationale for not disclosing (Table 4). The majority (n=46) were afraid of the child’s response to the disclosure. Other concerns identified included fear of being blamed by the child for infecting them (n=8), the child being too young to understand (n=7), concern of poor compliance following disclosure (n=5), fear of stigma (n=4), uncertainty of how to go about disclosing (n=1) and the mental competence of the child (n=1). There was a statistically significant difference in the rationale provided by caregivers according to their relationship to the child. Grandparents did not disclose because they were afraid of the 86

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Table 1. Characteristics of caregivers Disclosed

Non-disclosed

Age (years)

0.377

Range

18 - 64

19 - 72

Mean (SD)

43.54 (2.43)

40.63 (1.81)

23 (30.3)

53 (69.7)

No formal, primary

13 (48.1)

25 (34.2)

Secondary, tertiary

14 (51.8)

47 (64.3)

Gender (female), n (%) Education, n (%)

0.225 0.041

HIV status, n (%)

0.630

Positive

11 (26.8)

30 (73.2)

Negative

14 (26.4)

39 (73.6)

2 (50.0)

Unknown/unwilling to disclose

p-value

Table 2. Profile of children Disclosed Non-disclosed p-value Mean age (years)

11.6

10.7

Duration of treatment (years), n (%)

0.115 0.672

7 (30.4)

16 (69.6)

≥5

20 (25.9)

57 (74.1)

Number of hospital admissions, n (%)

0.030

1-2

13 (24.5)

24 (72.7)

3-5

9 (27.3)

40 (75.5)

4 (33.3)

8 (66.7)

Table 3. Process of disclosure Age at disclosure (years), mean (SD)

11.6 (0.33)

Person responsible for disclosure, % (n) Parent

84.6 (22)

Grandparent

11.5 (3)

Nurse

3.9 (1)

Process of disclosure, % (n) Alone

55.6 (15)

With assistance

44.4 (12)

Reason for disclosure Requested to disclose by healthcare worker

72.0 (18)

Child started asking questions about their illness

28.0 (7)

Child’s response, % (n) Already knew

40.7 (11)

Did not understand

40.7 (11)

Afraid

7.4 (2)

Angry

11.1 (3)

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ARTICLE Table 4. Profile of non-disclosure Reason for not disclosing, % (n) Fear of child’s response

63.0 (46)

Fear of blame

11.0 (8)

Fear of stigma

5.5 (4)

Other

20.5 (15)

Planned age of disclosure (years), mean (SD)

10.7 (0.33)

Planned person responsible for disclosure, % (n) Caregiver

19.2 (14)

Members of the family

65.8 (48)

Healthcare workers

15.0 (11)

Process of disclosure, % (n) Alone

21.9 (16)

With assistance

78.1 (57)

Anticipated response, % (n) Already suspected

23.3 (17)

Scared

68.5 (50)

Angry

4.1 (3)

Suicidal

4.1 (3)

emotional response of the children in 75% of cases, while only 45% of parents were afraid of the child’s emotional response. A higher percentage of parents (29%) were afraid that they would be blamed by their children for their illness compared with 4% of grandparents. The average age at which non-disclosing caregivers planned to inform their charge of their HIV status was 10.7 years. Most believed that responsibility for this disclosure lay with the child’s parents (84.6%); a smaller proportion allocated this responsibility to the grandparents (11.5%) and very few to the healthcare worker (3.8%). Two-thirds of caregivers (65.8%) indicated that they would seek assistance from their family when disclosing, 15% would seek assistance from a healthcare worker and 19.2% would disclose alone without any assistance. A quarter of caregivers (23.3%) believed that their children already suspected that they had HIV, two-thirds (68.5%) anticipated that their children would be scared at hearing the news, and a minority (4.1% each) anticipated that their children would either be angry or become suicidal upon hearing the news. The effect of HIV disclosure on the clinical wellbeing of the child was assessed by reviewing any effect on CD4 levels and HIV viral load (VL). The trend in both these parameters was similar in children in both the disclosed and undisclosed groups. In both groups the CD4 levels increased and the VL declined.

Discussion

Twenty-seven per cent of children in this study had been formally disclosed to regarding their HIV status. This lies within the range of disclosure reported in other developing countries, e.g. 17.4% in Ethiopia and 31% in Zambia,[9] but is three times higher than the 9% reported in Cape Town.[10] The three-fold variation in disclosure rates within SA may reflect the different periods during which the studies were conducted or a difference in HIV prevalence between these two communities at the times of each study, namely 6.0% in Cape Town[2] compared with 16.9% in KwaZulu-Natal. The age and gender of the caregiver as well as their relationship to the child did not influence whether they were more or less likely to disclose. Only two factors were found to influence disclosure, namely 87

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the educational level of the caregiver and the number of admissions of the child to hospital. We found a higher rate of disclosure among caregivers with a lower level of education. This was in line with reports from Ethiopia, Thailand and Cape Town. A study done in Ethiopia, where education was used as a proxy indicator of higher economic status, suggested that the lower rate of disclosure found in more affluent families resulted from fear that children would inadvertently disclose their HIV status and thereby bring shame on the family.[11] In our experience, where disclosure had occurred this was prompted by a healthcare worker in 72% of all cases, regardless of the caregivers’ educational level. Prompting may have influenced caregivers with a lower level of education to disclose without necessarily considering the broader social consequences of such disclosure, which a caregiver with a higher level of education may have considered as demonstrated in other studies.[11] Children with more than five admissions were found to have a higher rate of disclosure, and in more than half of these (60%) this was precipitated by questions from the child. This finding has not previously been reported and suggests that children may seek an explanation for poor health. The mean age at which disclosure occurred in this study was 11.6 years, which is higher than that found in the Cape Town study (9.4 years) but comparable with reports from developed countries, where the mean age ranged from 5 to 14 years.[10] Three-quarters of caregivers had not disclosed HIV status to their child even though the majority (93.2%) believed that the child has the right to know their HIV status. The reported mean age at which they intended to disclose the HIV status to their child was 10.7 years. This was the mean age of children to whom disclosure had not occurred, which suggests that they had probably not considered disclosure until the issue was raised as part of this study. Reasons reported for not disclosing were similar to those noted in previous studies,[5] namely fear of the emotional effect on the child, fear of blame for infecting the child and fear of stigma and ostracism. However, in this study there was less emphasis on fear of stigma as a reason for non-disclosure. The majority of caregivers (78%) indicated that they would require assistance from a healthcare worker in order to disclose. However in this study, a smaller percentage (44.4%) of caregivers actually required the assistance of a healthcare worker. Of the caregivers who had disclosed, 55.6% had done so independently without any assistance, although 72% only did so after prompting from the healthcare worker or in response to queries from their child. The response of children to disclosure differed markedly from what caregivers anticipated. Caregivers overestimated the adverse effect of disclosure on the emotional state of the child, with an emphasis on fear (68.5%), while in reality a minority of children reported such a reaction (7.4%). In contrast, caregivers underestimated how many children already suspected that they were HIV-positive (23.3%) compared with the number who actually suspected that they were infected (40.7%). There was no immediate clinical benefit noted in association with disclosure. Trends in the CD4 count and VLs were similar in children who were aware and who were not aware of their HIV status. This may be explained by the fact that the caregivers assumed responsibility for the collection and administration of treatment to their children and so adherence was more likely to be influenced by the knowledge and behaviour of the caregiver rather than the child. Mahloko and Madiba[9] found a similar lack of clinical improvement in response to HIV disclosure. Despite this, they suggested that disclosure remains an essential element in ensuring better compliance especially in the face of asymptomatic HIV disease, when there is a risk that children may stop taking their treatment.

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ARTICLE Findings of this study are comparable with those of previous reports, which show low levels of disclosure and an absence of immediate clinical benefit following disclosure. In addition, this study found that caregivers underestimate the knowledge and suspicion of their children and place undue emphasis on the emotional effect of disclosure on the child.

Conclusion

Despite recommendations from the American Academy of PaediaÂ trics[4] and local guidelines promoting the disclosure of HIV status to children, this remains a difficult and controversial issue with low rates of disclosure.[5] These low rates are underpinned by caregiversâ&#x20AC;&#x2122; fear of the emotional effect of disclosure on the child and fear of being blamed for the illness. Despite efforts to protect children from the knowledge of their disease, most children suspected that they had the virus due to frequent admissions and the need for daily treatment. Greater emphasis is required to encourage disclosure to older children. This should be facilitated by healthcare professionals during routine clinic visits. Locally available guidelines outline the process of progressive disclosure to ensure full disclosure by adolescence, with comprehensive understanding of the illness, the need for treatment compliance and the dangers of high-risk behaviour and transmission. HIV disclosure should therefore become an integral aspect in the comprehensive care for every child on ART.

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References 1. Department of Health. National Antenatal Sentinel HIV and Syphilis Seroprevalence Survey, 2009. Pretoria: Department of Health, 2010. 2. Shisana O, Rehle T, Simbayi LC, et al. South African National HIV Prevalence, Incidence and Behaviour Survey, 2012. Cape Town: Human Sciences Research Council Press, 2014. 3. Butler A, Williams P, Howland L, Storm D, Hutton N, Seage G. Impact of disclosure of HIV on health-related quality of life among children and adolescents with HIV Infection. Paediatr 2009;123(3):935-943. [http://dx.doi. org/10.1542/peds.2008-1290] 4. Naeem-Sheik A, Gray G. HIV disclosure in children. S Afr J HIV Med 2005;6(4):46-48. 5. Vaz ME, Eng E, Maman S, Tshikandu T, Behets F. Telling children they have HIV: Lessons learned from findings of a qualitative study in sub-Saharan Africa. AIDS Patient Care STDs 2010;24(4):247-256. [http://dx.doi.org/10.1089/ apc.2009.0217] 6. Wiener L, Mellins CA, Marhefka S, Battles HB. Disclosure of an HIV diagnosis to children: history, current research and future directions. J Dev Behav Pediatr 2007;28(2):155-166. [http://dx.doi.org/10.1097/01.DBP.0000267570.87564.cd] 7. American Academy of Paediatrics Committee on Paediatrics AIDS. Disclosure of illness status to children and adolescence with HIV infection. Paediatrics 1999;103(1):164-166. 8. McKerrow NH, Stephen CR, Purchase SE, et al. Step-by-step Guide for the Management of Children on ART. 4th ed. Pietermaritzburg: UNICEF, 2010. 9. Mahloko JM, Madiba S. Disclosing HIV diagnosis to children in Odi district, South Africa: Reasons for disclosure and non disclosure. Afr J Prim Healthcare Fam Med 2012;4(1):345-352. [http://dx.doi.org/10.4102/phcfm.v4i1.345] 10. Mokwena K, Mahloko J, Madiba S. Prevalence and factors associated with disclosure of HIV diagnosis to infected children receiving antiretroviral treatment in public health care facilities in Gauteng, South Africa. J Clin Res HIV/AIDS Prev 2014;1(1):35-45. 11. Biadgilign S, Derubrew A, Amberbir A, Escudero, HR, Deribe K. Factors associated with HIV/AIDS diagnostic disclosure to HIV infected children receiving HAART: A multicentre Study in Adis Ababa, Ethiopia. PLoS ONE 2011;6(3).

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ARTICLE

Adherence to case management guidelines of Integrated Management of Childhood Illness (IMCI) by healthcare workers in Tshwane, South Africa M C Mulaudzi, MB ChB, MMed (Paed), Dip HIV Man (SA) Department of Paediatrics and Child Health, Kalafong Hospital, University of Pretoria, South Africa Corresponding author: M C Mulaudzi (mphele.mulaudzi@up.ac.za) Background. Integrated Management of Childhood Illness (IMCI) is an essential strategy known to deliver childhood interventions that reduce the under-five mortality rate. Objective. To evaluate the adherence to the IMCI case management guidelines by primary healthcare workers in the Tshwane area, South Africa. Methods. The study was conducted between July and December 2012 on children referred from clinics to Kalafong Hospital. Data on IMCI clinical symptoms and signs, classification and treatment given at the clinics before referral to the hospital were collected from patients’ referral letters. An interview with the caregiver on counselling received at the clinic was done using an adapted World Health Organization health facility survey tool. Results. Eighty children between 2 and 60 months referred from 12 local clinics were included in the study. IMCI classification was done in just over half (52.9%) of 34 children with cough and 73% of 15 children with diarrhoea. Only 18% of children with chest indrawing and fast breathing were classified correctly. Prereferral treatment for all children with severe dehydration had been given correctly but not so for children with severe pneumonia and severe malnutrition. None of the children with severe disease had been checked for glucose levels before referral. Conclusions. The IMCI guidelines had not been adhered to in all children referred to the hospital. Children, particularly those with severe disease, had been incorrectly classified, leading to inadequate prereferral treatment. Healthcare workers had not given the expected treatment at the clinic before referral. S Afr J Child Health 2015;9(3):89-92. DOI:10.7196/SAJCH.7959

Globally, the Integrated Management of Childhood Illness (IMCI) is a strategy that has been shown to reduce the under-five mortality rate (U5MR) and to assist in the realisation of the Millennium Development Goals (MDGs).[1,2] South Africa (SA) adopted the IMCI strategy in 1996, with the first training of healthcare workers (HCWs) in case management in 1998. By 2001, all provinces had trained some healthcare workers but the coverage varied from province to province.[3] Despite SA adopting the IMCI strategy, 47 417 children <5 years old (35 318 beyond neonatal period) died in 2010 from mainly neonatal conditions, pneumonia, diarrhoea, HIV and malnutrition. Beyond the neonatal period, the latter four conditions contributing to U5MR are included in the IMCI case management guidelines in an attempt to reduce case fatality rates.[4] The IMCI strategy was developed by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) in the early 1990s to reduce the U5MR through the integrated management of common childhood diseases, in contrast to vertical programmes that focused on individual disease. The IMCI strategy has three components, namely case management guidelines, health system strengthening and community health messages. The case management guidelines of the IMCI use algorithms of specific symptoms and clinical signs. The patient’s condition is classified and recommended treatment administered, including treatment administered at the clinic before hospital referral (prereferral treatment).[5] The major difference from the usual assessments of children is that classification of severity of illness rather than diagnosis is used. 89

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SA research has shown that training in the IMCI case management guidelines improves HCWs’ ability to assess, recognise signs of severe illnesses and treat sick children appropriately.[6,7] In order for the IMCI strategy to reduce U5MR, the majority of HCWs, if not all, ought to be trained and need to adhere to the guidelines. Recent data on the numbers and the coverage of IMCItrained HCWs in SA are not available. Chopra et al.[6] have shown that although the guidelines are used, they are not implemented correctly or completely.[5] The Saving Children Report of 2010 2011, by the Child Healthcare Problem Identification Programme (Child PIP), identified failure to follow IMCI assessment and treatment guidelines and failure to recognise the severity of illness as modifiable factors responsible for the death of children in SA, supporting the findings by Chopra et al.[6] that IMCI guidelines are not followed.[8] Research on adherence to the IMCI case management guidelines has been carried out in the primary healthcare (PHC) clinic setting. No research was found to have been carried out in the referral hospital setting to assess adherence to the IMCI guidelines. The motivation to conduct this study in the hospital setting was to reduce the likelihood of the Hawthorne effect, where HCWs in clinics might adhere to guidelines because they are being observed for research purposes. The methodology has some limitations in that it relies on the documented information in the referral letter and the condition of the patient might have changed en route to the hospital. In view of the high U5MR and the varied coverage of IMCItrained HCWs, the research was conducted at the hospital, with the objective of assessing the adherence to IMCI case management guidelines by HCWs at the clinic level.

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ARTICLE Method

Study design and setting

The study was conducted at Kalafong Hospital in Pretoria, SA. This was a cross-sectional study conducted between July and December 2012. Convenience sampling was used. All children referred from PHC clinics to Kala fong Hospital were recruited between 08h00 and 16h00 on the days when the researcher was available (on average 1 day per week) as there was no funding to employ a full-time person to conduct the research. The PHC clinics that refer to Kalafong Hospital operate on weekdays between 07h00 and 16h00 and on Saturdays in the morning till 13h00. There is only one clinic that operates 24 hours a day, including weekends and holidays.

Participants and eligibility criteria

Children aged 2 - 60 months referred from clinics to Kalafong Hospital with medical conditions were recruited. Children referred with surgical and dermatological problems were excluded. On average, 16 - 20 cases are referred daily from PHCs to the paediatrics outpatient department (POPD) over a 5-day working week. The POPD is closed after 16h00 and over weekends. It was anticipated that the subjects would be recruited over a period of 8 - 10 weeks with the assumption that ~50% would give consent to be recruited into the study, thus giving a minimum sample size of 80 subjects for analysis.

Measurement and tools used

Information on IMCI clinical symptoms and signs, classification and prereferral treatment documented in patients’ referral letters was collected. Information on counselling received by caregivers regarding the child’s condition at the clinic before referral was collected in an interview with the caregiver on arrival at the hospital. A questionnaire adapted from the WHO health facility survey tool to evaluate the quality of care delivered to sick children attending the outpatient facility was used.[9] The IMCI guidelines require that at each consultation of a child aged between 2 and 60 months, HCWs should follow specific steps. Firstly, they should assess for general danger signs, i.e. the inability to drink or breastfeed, the child vomiting everything, convulsions during this illness, and lethargy or unconsciousness. Secondly, the HCW should ask the caregiver about the four main symptoms, i.e. cough or difficulty in breathing, diarrhoea, fever and ear problems. For each symptom present, a list of clinical signs should be checked in the child for the IMCI classification to be done; classifications are categorised according to the severity of the illness. Thirdly, the HCW should consider the following conditions: measles, HIV infection and tuberculosis (TB) if clinical symptoms and signs listed for consideration are found.

Nutritional and immunisation status should also be checked in all children. Treatment is then recommended according to the classification of the condition.

Statistics

The data were entered into an Excel (Microsoft, USA) spreadsheet, cleaned and then imported into Stata statistical software release 12 (StataCorp, USA) for statistical analysis.

Ethics

Ethical approval was granted by the Faculty of Health Sciences Research Ethics Committee, University of Pretoria. Informed consent was obtained from parents who agreed to participate in the study.

Results

A total of 110 children were recruited into the study. Children between 2 and 60 months old who met the inclusion criteria and with written consent to participate in the research were enrolled. During the study period, 699 new patients were referred to the POPD (not only from the PHC clinics). Of the original 110 recruited, 80 children were enrolled – 30 with surgical and dermato logical conditions were excluded. A total of 52 of the 80 children were male. Half of the children were <1 year old. Children were referred from 12 surrounding clinics in the Tshwane subdistricts 3 and 4.

Presenting symptoms

Of the 80 children enrolled, 55 had documented four IMCI symptoms (cough or difficulty breathing, diarrhoea, fever or ear problem), 13 had other symptoms, and 12 had no documented symptoms but were referred for malnutrition, HIV, TB or measles. A total of 76 occurrences of IMCI symptoms in 55 children and 15 occurrences of non-IMCI symptoms were documented in the referral letters. Not all referral letters had symptoms documented. The most common single symptom at presentation was cough, followed by diarrhoea and fever (Table 1). Thirty-four (42.5%) patients presented with multiple symptoms. The only general danger sign documented was lethargy in an infant who presented with cough and diarrhoea; this was classified as cough and cold, and severe dehydration. The patient received ceftriaxone and co-trimoxazole before referral to the hospital.

IMCI classification and management

For each of the four IMCI presenting symp toms, the signs and classification documented in the referral letter were identified. Table 2 shows the clinical signs, classifications and urgent prereferral treatment given at the clinic before referral to the hospital. 90

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IMCI classification was done in just over half (52.9%) of 34 children with cough and 73% of 15 children with diarrhoea. Only 18% of children with chest indrawing were classified correctly as severe pneumonia, and half with fast breathing were classified correctly. A total of 5 cases were classified as TB exposure, 11 as probable TB, 2 as symptomatic HIV, 10 as HIV-exposed and 1 as measles. Nutritional assessment was only recorded in 24 (30%) children, with 6 as severe malnutrition, 8 as not growing well and 10 as growing well. Four children had anaemia classification. ‘Normal weight’ was mostly used rather than the IMCI term ‘growing well’ in the referral letters. Of the six children with severe malnutrition, only one had received vitamin A, three had received antibiotics, and blood glucose levels had not been checked in any of them.

Counselling

Counselling of 59 (73.7%) caregivers on the condition of the children was done at the clinics before referral of the children to the hospital (Table 3). Caregivers were counselled on the medical condition of the child, immunisations, how to administer treatment and how to recognise symptoms and signs that indicate when the child should return to the health facility. Table 1. Frequency of the four IMCI symptoms Symptom

Cough or difficulty in breathing (cough)

Cough only

Cough and diarrhoea

Cough and fever

Cough, diarrhoea and fever

Cough and ear problem

Diarrhoea

Diarrhoea only

Diarrhoea and cough

Diarrhoea and fever

Diarrhoea, cough and fever

Fever

Fever only

Fever and cough

Fever and diarrhoea

Fever and ear problem

Ear problems

Ear problem only

Ear problem and fever

Ear problem and cough

ARTICLE Table 2. IMCI clinical signs, classification and prereferral treatment Presenting symptoms (n) Cough and difficulty breathing (34)

Diarrhoea (15)

Fever (22)

Ear problems (5)

IMCI signs as documented in referral letter (n)

Total IMCI classification as documented in referral letter (n)

Percentage of IMCI classification done per clinical signs

Percentage of IMCI classification correctly assigned per clinical signs

Percentage of total IMCI classification done per symptoms

Treatment given at clinic before referral according to documented classification (both correct and incorrect)

Chest indrawing (11)

Severe pneumonia or very severe disease (4)

4/11 = 36.4%

2/11 = 18.2%*

4+6+2+2+4 = 18/34 cough symptoms = 52.9%

3 received ceftriaxone 1 received co-trimoxazole 3 received oxygen No glucose done

Fast breathing (14)

Pneumonia (6)

6+2+2 = 10/14 = 71.5%

4+1+2 = 7/14 = 50%

3 received amoxicillin 1 received co-trimoxazole 3 received inhalation

Wheeze, first episode (2)

Recurrent wheeze (2)

No fast breathing (4)

Cough and cold (4)

4/4 = 100%

3/4 = 75%

Lethargy (2)

Severe dehydration (3)

Other signs required to come to classification were not recorded

3+7+1 = 11/15 diarrhoea symptoms = 73%

All received IVI fluid

Sunken eyes (7)

Some dehydration (7)

No documentation of ORS

Absent (3) (drinking well, no sunken eyes, no lethargy)

No visible dehydration (1)

1/3 = 33%

Stiff neck or bulging fontanel (2)

Suspected meningitis (1)

Fever alone only occurred in 6â&#x20AC;&#x201A; instances

2/6 fever alone symptoms = 33.3%

1 received ceftriaxone

Absent (no stiff neck or bulging fontanel) (1)

Suspected severe malaria (1)

10/22 (45.4%) received paracetamol

Ear pain (1)

Acute ear infection (1)

1/1 = 100%

1/5 ear problem symptoms = 20%

Only 1 patient with ear pain and severe malnutrition received ceftriaxone

Pus draining for <14 days (1)

No swelling behind the ear (1)

IVI = intravenous fluid infusion; ORS = oral rehydration solution. *The other 2 did not have the clinical sign, chest indrawing; 1 had only fast breathing and 1 was very ill with severe malnutrition and probable TB.

Discussion

The results of the study suggest that the IMCI case management guidelines are not adhered to in the assessment and management of children by clinic HCWs before referral to Kalafong Hospital. The classification of the conditions was incomplete and incorrect in some cases, as only 18% of children presenting with cough and chest indrawing were correctly classified as severe pneumonia. The recommended prereferral treatment at the clinic was not always administered. Forty-two per cent of children presented with multiple symptoms. This high percentage indicates the value of the integrated guidelines 91

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as opposed to single disease-focus guidelines. The high percentage of multiple symptoms also suggests the appropriateness of the referrals. However, some symptoms were not addressed by the IMCI case management guidelines. IMCI classifications were not done for all the presenting symptoms in children presenting with multiple symptoms; this finding concurs with that in a study done by Walter et al.[10] in Tanzania. In the studies done by Chopra et al.[6] in Cape Town and Horwood et al.[7] in KwaZulu-Natal and Limpopo, incorrect classification was found mainly for the symptoms cough and diarrhoea, and for the sign very low weight; the same applied in this study.

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ARTICLE Table 3. Counselling received by caregivers at the clinic before referral of children to the hospital Topic

Counselling done, n (%)

Counselling not done, n (%)

Counselling information missing, n (%)

Immunisation

59 (73.7)

2 (2.5)

19 (23.7)

Medical condition

61 (76.2)

18 (22.5)

1 (1.2)

Administration of treatment

47 (58.7)

27 (33.7)

6 (7.5)

Oral hydration solution reconstitution

20 (25.0)

26 (32.5)

34 (42.5)

return to the health facility was low, possibly because the patients were being referred to the next level of care rather than going home.

Study limitations

It is not known whether the primary HCWs who saw the children were IMCI trained. Another limitation is that not everything done to the patient at the clinic had been documented in the referral letter. Prereferral treatment given at the clinic but not documented in the referral letter may result in a child receiving high or excessive doses of medication, which might have side-effects. Children managed at the clinic level by healthcare workers not IMCI trained means that the high coverage of IMCI interventions required to have child survival benefits is not reached.

Conclusion

IMCI guidelines were not always adhered to and IMCI classifications for children referred from clinics to the hospital were often incorrect and incomplete. Children with chest indrawing and fast breathing were classified incorrectly, resulting in inappropriate treatment being received before referral to hospital. Nutritional status was documented in only one-quarter of children referred. None of the children with severe pneumonia and severe malnutrition had glucose levels checked before referral. We recommend that the HCWs in PHC clinics be trained and supported to use the IMCI guidelines. Messages to HCWs about the chest indrawing sign should have the same importance as the IMCI general danger signs, even though the WHO no longer recommends this sign as needing referral. We also recommend that appropriate IMCI referral forms or equivalent should be used to assist in adequately documenting information and treatment done at the clinic before referral.

Danger signs Fever

14 (17.5)

52 (65.0)

14 (17.5)

Fast breathing

19 (23.7)

45 (56.2)

16 (20.0)

Blood in the stool

7 (8.7)

38 (47.5)

35 (43.7)

Difficulty breathing

16 (20.0)

49 (61.2)

15 (18.7)

Not able to drink or feed

33 (41.2)

38 (47.5)

9 (11.2)

Convulsions

8 (10.0)

41 (51.5)

31 (61.2)

Child becoming sicker

48 (60.0)

32 (40.0)

Incorrect classification resulted in severe classifications being classi fied as less severe categories in our study, a finding which concurs with those of Horwood et al.[7] and Walter et al.[10] Certain individual clinical signs, such as chest indrawing and very low weight, categorise the condition as severe without the need for another sign; as such these signs should have the same importance as general danger signs to prevent afflicted children from being sent home and to facilitate their immediate attention in health facilities. Prereferral treatment was done well for children with severe dehydra tion, which is an improvement from the previously stated studies. [6,7] However, fewer children with severe pneumonia received ceftriaxone, co-trimoxazole and oxygen before referral, which are considered essential interventions to reduce death due to pneumonia.[11] None of the children with severe malnutrition received vitamin A, similar to the 9% reported by Chopra et al.[6] The importance of vitamin A appears not to be realised by HCWs, as the administration of vitamin A to children is still very low, more than 10 years on from its recommended implementation in IMCI. Blood glucose was also not checked in all children with severe pneumonia and severe malnutrition, resulting in failure to recognise hypoglycaemia, a cause of death in children with severe acute malnutrition. Besides incorrect and incomplete classifications, very few children had nutritional and HIV status assessed, and treatment was not given according to guidelines. Assessment for severe malnutrition and HIV is important as these children may require additional care before transfer to hospital, which may improve survival. Pneumonia, diarrhoea and malnutrition are leading causes of death for <5-year-olds.[4,11,12] To reduce the U5MR, the IMCI case management of these conditions ought to be adhered to before hospital referral. It was encouraging to learn that two-thirds of caregivers were counselled on the medical condition of the child, on the importance of immunisations and on the need to return to the clinic if the child got sicker. Counselling on the clinical signs to be used to determine when to 92

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Acknowledgements. Dr Campos for data collection, Dr Olorungo for statistical input and Prof. Wittenberg for encouragement.

References

1. Jones G, Steketee R, Black R, et al. Child survival II: How many child deaths can we prevent this year? Lancet 2003;362(9377):65-71. [http://dx.doi.org/10.1016/ S0140-6736(03)13811-1] 2. Chopra M, Mason E, Borrazzo J, et al. Ending of preventable deaths from pneumonia and diarrhoea: An achievable goal. Lancet 2013;381(9876):14991506. [http://dx.doi.org/10.1016/ S0140-6736(13)60319-0] 3. World Health Organization (WHO), United Nations International Children’s Fund (UNICEF), Italian Government. Report of IMCI Health Facility Survey Free State, Gauteng and Western Cape. Pretoria: Business print centre, 2003. 4. Statistics South Africa. Mortality and Causes of Death in South Africa, 2010: Findings from Death Notification. Pretoria: Statistics South Africa, 2013. 5. Gove S. Integrated management of childhood illness by outpatient healthcare workers: Technical basis and overview. The WHO working group on guidelines for integrated management of the sick child. Bull World Health Organ 1997;75(Suppl 1):7-24. http://whqlibdoc.who.int/bulletin/1997/supplement/ bulletin_1997_75(supp1)_7-24.pdf (accessed 22 September 2014). 6. Chopra M, Patel S, Cloete K, Sanders D, Peterson S. Effect of an IMCI intervention on quality of care across four districts in Cape Town, South Africa. Arch Dis Child 2005;90(4):397-401. [http://dx.doi.org/10.1136/adc.2004.059147] 7. Horwood C, Vermaak K, Rollins N, Haskins L, Nkosi P, Qazi S. An evaluation of the quality of IMCI assessments among IMCI trained health workers in South Africa. PLoS ONE 2009;4(6):e5937. [http://dx.doi.org/10.1371/journal.pone.0005937] 8. Stephen CR, Bamford LJ, eds. Saving Children 2010 - 2011: A Seventh Survey on Child Healthcare in South Africa. Pretoria: Tshepesa Press, MRC, CDC, 2013. 9. WHO. WHO Health Facility Survey: Tool to Evaluate the Quality of Care Delivered to Sick Children Attending Outpatient Facility. Geneva: WHO, 2003. 10. Walter ND, Lyimo T, Skarbinski J, et al. Why first-level health workers fail to follow guidelines for managing severe disease in children in the Coast Region, the United Republic of Tanzania. Bull World Health Organ 2009;87(2):99-107. [http://dx.doi.org/10.2471/BLT.08.050740] 11. Gill CJ, Young M, Schroder K, et al. Bottlenecks, barriers, and solutions: Results from multicountry consultations focused on reduction of childhood pneumonia and diarrhoea deaths. Lancet 2013;381 (9876):1487-1498. [http:// dx.doi.org/10.1016/S0140-6736(13)60314-1] 12. United Nation International Children’s Fund (UNICEF), developed by the UN Inter-agency Group for Child Mortality Estimation. Levels and Trends in Child Mortality, Estimates 2013 Report. New York: UNICEF, 2013. http://www.childinfo. org/files/Child_Mortality_Report_2013.pdf (accessed 22 September 2014)

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Viability in delivering oral health promotion activities within the Health Promoting Schools Initiative in KwaZulu-Natal M Reddy, MDent PH; S Singh, PhD Discipline of Dentistry, School of Health Sciences, University of KwaZulu-Natal, Durban, South Africa Corresponding author: M Reddy (reddym@ukzn.ac.za) This work is part of a larger study conducted in fulfilment of the first author’s PhD degree in Health Sciences, University of KwaZulu-Natal.

Background. The Health Promoting Schools Initiative can provide a platform to explore integration of oral health promotion activities within the broader context of healthcare delivery. Objectives. To understand the contextualised delivery of oral health service provision within Health Promoting Schools, to conduct a situational analysis of existing services provided at these schools and to review current health and education policies. Methods. The explorative study design used a mixed methods approach. Twenty-three schools of a total sample of 154 were selected using multistage cluster sampling. Data collection comprised policy reviews, a self-administered questionnaire, a data capture sheet and an interview schedule. The study was approved by the Humanities and Social Sciences Research Ethics Committee of the University of KwaZulu-Natal (HSS/0509/013D). Results. Although policies included statements on oral health promotion, this was not translated into practice at school level. Barriers and challenges identified for successful implementation of an oral health promotion programme included lack of funds, human resources, knowledge and ownership, as well as high workloads and time constraints. Conclusion. Current delivery of oral health promotion services within the Health Promoting Schools Initiative will not reap the desired oral health outcomes owing to the inherent mismatch between policy planning and implementation. More research needs to be conducted to address opportunities and challenges facing educators and other oral healthcare providers working in the school environment. S Afr J Child Health 2015;9(3):93-97. DOI:10.7196/SAJCH.7944

The Health Promoting Schools Initiative is recognised as a viable platform to provide integrated and compre hensive oral healthcare. [1] This approach differs from traditional school-based settings in that greater account ability is placed on supportive environments, develop ment of school-based policies, community participation, and focus on disease prevention and promotion of healthier lifestyles.[1] The initiative can provide a platform to explore integration of oral health promotion activities within the broader context of healthcare delivery. Oral healthcare should be seen as an essential part of general health. Interventions could include promotion of a healthy diet, oral health education, tobacco cessation, safe water and sanitation, water fluoridation, tooth brushing and fluoride rinsing programmes.[2] Schools in South Africa (SA) are graded according to quintiles, which range from quintile 1 (the poorest) to quintile 5 (least poor). Presently, school health services give greater priority to quintile 1 and 2 schools. [3] The literature suggests an inequitable distribution of school health services in KwaZulu-Natal.[3] This could be due to multiple factors that include shortage of personnel, transport and equipment. [3,4] These challenges are more prevalent in rural communities and, given the burden of oral diseases and huge unmet oral health need, these problems are further compounded by access and availability of health services.[5] School oral health promotion programmes currently in place are inconsistent, inequitably distributed and lack monitoring and evaluation.[5] There are over 1 000 Health Promoting Schools that have been established in SA since 1999.[6-8] However very little research has been done to assess the progress of this initiative, specifically in relation to oral health promotion in KwaZulu-Natal. 93

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International experience indicates the importance of con ducting a needs analysis prior to the implementation of health programmes. Understanding of the system’s capacity (in this case the school) to support programme implementation – in terms of resources, budgetary allocations, inclusive decision-making and monitoring and evaluation – will contribute to the programme’s sustainability. A needs analysis could include sociodemographic profile, socio economic status, health and oral health status, availability of dental and school health services, nutritional status, infrastructure, available resources, funding and evidence of community participation. This presentation is part of a bigger project that examines the viability of integrating oral health promotion activities within the Health Promoting Schools Initiative. This article reports only on the current capacity of Health Promoting Schools to support oral health promotion in KwaZulu-Natal.

Objectives

To understand the contextualised delivery of oral health service provision within Health Promoting Schools, to conduct a situational analysis of existing services provided at these schools, and to review current health and education policies.

Methods

The explorative study design used a mixed methods approach, with a combination of qualitative and quantitative data. Data source triangulation was used to combine evidence from multiple data sources. A structured self-administered questionnaire, data capture sheet and interview schedule were used to collect data. Policies were

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ARTICLE also reviewed for identification of current policy priorities in health and oral health promotion. There are 154 primary Health Promoting Schools in KwaZulu-Natal. Twenty-three schools were selected from the 11 districts using multistage cluster sampling. Schools were selected according to districts and then quintiles. The study sample (n=23) comprised two or three schools from each district and four or five from each quintile. The sample population for the interview phase comprised the Basic Education manager involved with health promotion, and the provincial and district (eThekweni, Ugu, iLembe and Uthukela) health promotion managers from the Department of Health. These participants were selected using purposeful random sampling. The self-administered questionnaire, which focused on oral health promotion, school health services, community relationships and collaboration, and barriers and challenges experienced, was completed by school principals. Fieldworkers involved in data collection observed and recorded the school’s physical and environmental condition on a data capturing sheet. The interview schedule included questions on the importance and awareness of oral health promotion at schools, and opportunities and challenges facing integration of oral health promotion services. A pilot study was conducted to pretest the questionnaire at two schools not included in the study, prior to commencement of data collection. Validity was maintained by ensuring that the questionnaire and interview focused on the study’s objectives. Reliability was ensured by standardising the use of codes and identified themes. Gatekeeper permission was obtained from Department of Health and Department of Education. The study was approved by the Humanities and Social Sciences Research Eth ics Committee of the University of KwaZulu- Natal (HSS/0509/013D). The University of KwaZulu-Natal ethical guidelines were used to ensure confidentiality, consent to conduct interviews and proper data management.

Results

The results of the study are a combination of quantitative and qualitative data, and are presented to address the objectives of the study.

no direct mention of oral health promotion in these policy statements. The SA National Oral Health Strategy (2004)[9] and Draft National Oral Health Strategy (2010)[10] prioritised the improvement of oral health for all citizens through oral health promotion. School screenings for oral health were mentioned in the School Health Policy and Implementation Guidelines[3] and Integrated School Health Policy.[4] However, reports from interviews with managers indicated a lack of priority given to oral health, as reflected in the following quotation: ‘There is awareness to [sic] basic hygiene being included in the curriculum but not oral health’ (interview with Manager A). Managers did, however, identify the need to give priority to oral health promotion: ‘Oral health promotion was identified as a critical gap in the Health Promoting Schools Initiative and it is vital that it be part of the health promotion programme so that it would enable children to take care of their teeth and prevent long-term oral health problems’ (interview with Manager C). Responses to the questionnaire for school

Situational analysis

The majority (60.9%) of schools in the study sample (n=23) were located in rural areas, 26.1% (n=6) in peri-urban areas and only 13% (n=3) were located in urban areas. An assessment of the condition and environment of the schools is outlined in Table 2. All respondents (n=14) (Table 2) in the rural areas and 89% of respondents in the urban and peri-urban areas reported that health messages formed part of the curriculum. Water supply and safety in the urban and peri-urban areas was reported as good (100%) compared with rural water supply and safety (64.3%). Most respondents in the rural areas (78.6%) and 44.4% in the urban and peri-urban areas reported that recycling was inadequate. Playground conditions in the rural areas were reported as inadequate (57%) compared with 33.3% inadequate in the urban/peri-urban areas. Only 50% of the

Table 1. Policy and priorities Document

Priorities [9]

National Oral Health Strategy (2004) National Oral Health Strategy (Draft: 2010)[10]

Interventions Primary prevention and promotion, integrated approach, common risk factors Resources required Oral health personnel, physical facilities, funding, transport

KwaZulu-Natal Department of Health Vote 7 Annual Report 2011/2012[11]

Interventions School-based preventive and promotive oral health programme Resources required Oral health personnel, facilities, equipment

Policy Guidelines for Youth and Adolescent Health (2001)[12]

Interventions Primary prevention and promotion, integrated approach, common risk factors School health services

Department of Health Strategic Plan 2010 - 2014 (2010)[13]

Interventions Primary prevention and promotion, integrated approach, common risk factors Resources required Human resources, funding, staff accommodation

School Health Policy and Implementation Guidelines (2011)[3]

Interventions Primary prevention and promotion, integrated approach, common risk factors School screenings for oral health Resources required Nursing personnel for school health services

Integrated School Health Policy (2012)[4]

Interventions Primary prevention and promotion, integrated approach, common risk factors School health services Screenings for oral health

Policy document review

Table 1 presents the list of policies and documents that were reviewed. The Youth and Adolescent Policy[12] and Integrated School Health Policy[4] identified the need to improve and strengthen existing school health services. However, there was

principals indicated that five schools (21.8%) had comprehensive oral health policies in place but only one school provided supporting evidence.

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ARTICLE Table 2. Conditions and environment of the schools Rural (n=14), %

Urban/periurban (n=9), %

Poor

Good

Poor

Good

p-value

Sanitation or toilet condition or number

50.0

22.2

77.8

0.677

Water supply and safety

35.7

64.3

100

0.043

Refuse disposal: type/bins

50.0

11.0

89.0

0.148

Recycling programme in place

78.6

21.4

44.4

55.6

0.005

Health messages form part of the curriculum content

100

11.0

89.0

0.130

Playground conditions

57.0

43.0

33.3

66.7

0.266

77.3

80 70

63.6

Percentage (%)

45.5

50 36.4

59.1

54.5

40.9

36.4

22.7

Yes No

20 10

re tu

Ag ric

Se xu

n tio tri Nu

To b

cy cli

ac co

Fig. 1. Community activities.

100 90

81.8

77.3

80 Percentage (%)

95.5

90.9

70 54.5

45.5

50 40 30 20

18.2

22.7 9.1

10 0

Education Toothbrushing Flouride Fissure sealant programme mouthrinse programme Yes

Priorities for health promotion and oral health promotion

4.5 Other

Fig. 2. Oral health services.

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respondents in the rural areas reported that sanitation and the condition or number of the toilets was fine. Seven respondents (77.8%) in the urban/peri-urban areas were satisfied with sanitation and availability of toilets. All respondents indicated that 71.4% of the schools had clinics in close proximity to the schools, while 57.1% indicated that hospitals and police stations were located within a 30 km radius. Recreational facilities such as sporting activities were not easily accessible to 71.4% of the schools. Respondents from the rural areas also reported that road conditions were poor and transport and resources limited. Eighty-seven per cent of respondents reported that School Health Services and screenings were provided annually by the Department of Health. Supporting evidence was provided in the school visitors log book. Responses from interviews with provincial and district health managers (100%) indicated that school health nurses lacked expertise and knowledge in oral health promotion, had large areas to support, and had high workloads and limited staff and resources. Respondents also stated that there should be an increase in human resources, especially oral hygienists. The Department of Health Strategic Plan 2010 - 2014[13] further validates this view by suggesting an increase in the employment of dental health practitioners. Forty-eight per cent of the study sample indicated that community involvement in school health programmes was voluntary, and that some parents expected payment for their assistance. The activities that communities were involved in are illustrated in Fig. 1. These activities include HIV/AIDS (77.3%), sexual abuse (54.5%) and agriculture (59.1%), compared with recycling (36.4%), tobacco use (36.4%) and nutrition and food safety (45.5%). Eighty per cent of rural schools indicated community awareness in nutrition, basic hygiene, cleanliness and gardening. A small percentage (13.6%) of schools indicated an improvement in nutrition as indicated by the following response: ‘Pupils eat healthy foods from the nutrition programme and the community is aware that the school promotes healthy food’ (response to questionnaire).

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Of the total sample (n=23) of schools, 72.7% of respondents indicated oral health services in place. Oral health services offered at the schools is illustrated in Fig. 2. Oral health education (81.8%, p=0.003) was the most common activity conducted at schools, and fissure sealant placement (9.1%, p=0.000) the least. However, supporting evidence in school record books indicated that there was

ARTICLE inconsistency in these activities, as they occurred only once at one of the schools and once a year in 65% of the schools. The sale of healthy foods was mentioned by three respondents (13%). The majority of the respondents (87%) indicated major barriers in the sale of healthy foods to children, e.g. ‘Tuck shop outsourced – limited control’ and ‘No healthy foods are sold at the tuck shop’ (responses to questionnaire). Health promotion training for school staff was not present in the majority (61.9%) of the schools. This was also highlighted as a problem by the district managers. Staff indicated that they lacked basic knowledge in oral health, which resulted in a lack of confidence in the implementation of oral health promotion programmes. Challenges experienced by staff for the implementation of an oral health promotion programme included lack of resources (22%), funds (26%), time constraints (22%), large classes (4%) and support from parents and community (30%).

Discussion

The policy process is recognised as an integral component to guide implementation and sustainability of a programme.[5,14] One of the key policy priorities identified was a need for an integrated approach to health that looked at common risk factors; however, this was not evident as very little priority was given to oral health. Poor oral health and chronic diseases such as cancers, cardiovascular diseases and trauma share common contributory factors such as poor hygiene and diet, smoking and alcohol abuse. The common risk factor approach, which is a more collaborative approach, should therefore be adopted to avoid duplication and to improve the effectiveness and efficiency of health programmes.[15] The study findings indicated that school principals expressed lack of knowledge and understanding on related health and education policies, compounded by a lack of support from the Department of Education. Oral health screening is included in The Integrated School Health Policy,[4] but there was no evidence of oral health education as a formal component in the school curriculum. Oral health promotion was also perceived as an additional burden on the teaching workload and was not part of the daily routine programme owing to time constraints, high workloads, lack of knowledge and confidence. It is imperative that oral health education be formally included into the school curriculum. Although the study findings indicated an array of oral health promotion activities at the schools (Fig. 2), caution must be exercised in the interpretation of these results as these activities were conducted either once or occurred only once a year. These findings therefore highlight the need for greater collaboration and dialogue between the Departments of Health and Education. Shared resources for oral health screenings and oral health promotion programmes would relieve the burden on resources and could contribute to greater programme sustainability. Commitment from the national, provincial and regional Departments of Health and Education and schools is critical. This commitment requires strategic planning and resource allocation that could support and ultimately sustain the delivery of the integrated school health programmes. Designated educators at school should work in close collaboration with health and oral health personnel with greater accountability and ‘ownership’ in these programmes. Further research needs to be conducted to assess the challenges facing educators with these additional responsibilities. The policy review revealed that the KwaZulu-Natal Department of Education Draft National School Nutrition Programme Policy[16] had guidelines for school vendors and tuckshops. However, findings in this study suggest that this has not been translated into practice. Major barriers were encountered by schools in the sale of healthy foods to children by vendors and tuckshop owners. Although vendors and tuckshop owners were educated and encouraged to 96

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buy into the notion of healthy eating, this was not always practical. Healthy foods were seen as too expensive. Schools need to negotiate formal contracts with tuckshop owners and vendors to ensure alignment with the policy. More research is required to further address the challenges related to the implementation of healthy nutritional policies in schools. Financial restraints and a high turnover (27.7%) and vacancy rate (37.3%) for dental health practitioners were also identified in the Department of Health Strategic Plan 2010 - 2014.[13] The vacancy rate for oral hygienists was 51.9%, negatively affecting oral health education and school screening services.[13] It was also noted that the sustainability of programmes at schools was a challenge due mainly to poor buy-in from the Department of Education.[13] Oral health personnel were mostly hospital based and provided more curative rather than preventive services.[5,17] District managers also reported that preventive programmes did not receive recognition for prioritisation for budgetary allocations. Oral health promotion requires a dedicated budget. The strategy for the Oral Health 10 Point Plan (2011 - 2015) [11] in KwaZulu-Natal includes the establishment of comprehensive preventive and promotive oral health programmes; however, current shortage of oral health personnel affects the delivery and sustainability of these programmes.[18] The draft National Oral Health Strategy (2010) indicates that oral health promotion and services should be included in health promotion at schools and that nurses, teachers and community health workers should be utilised for oral health promotion programmes.[10] In view of the challenges being faced by educators and school health services, a needs analysis and epidemiological profile should be performed so that resource allocation is based on unmet oral health needs and is in response to the needs of the community. There should also be ongoing stakeholder involvement from the planning to the execution and evaluation of oral health interventions. Additional funding needs to be allocated and more nurses and oral health personnel employed for the success of these strategies and interventions. Policy formulation and strategic planning must include educators and healthcare workers at grassroots level for the successful implementation and sustainability of oral health promotion programmes. More research needs to be done to support the translation of policy into practice. The focus should be on the process of how these interventions are executed and monitored. Community support services such as hospitals and clinics are integral for follow-up to school health visits. Although the availability of community support services in rural areas was identified in this study, these are not easily accessible owing to poor roads and transport, and limited resources.[10,13] The study findings revealed that the conditions and environment of schools were generally good and compliant with the requirements of a Health Promoting School; however, attention still needed to be given to recycling, condition of playgrounds and sanitation in rural areas. Community awareness and participation was poorly defined and inconsistent. The results further indicated that communities were not aware of available preventive services and follow-up practice for oral health. Schools need to create awareness and improve links with communities through in-depth community engagement programmes in order to facilitate community participation and ownership in decision-making processes. This would be in keeping with requirements of a Health Promoting School.[1] The availability of clean water and other resources could create challenges in terms of uninterrupted delivery of oral health promotion activities. Furthermore, resources required to ensure healthy lifestyle practices are not available to most families in rural and semirural communities.[6,19,20]

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ARTICLE Conclusion

The results of this study indicated that current delivery of oral health promotion services within the Health Promoting Schools Initiative will not reap the desired oral health outcomes due to the inherent mismatch between policy planning and implementation. More research needs to be conducted to address the opportunities and challenges facing educators and other oral healthcare providers working in the school environment. References

1. World Health Organization (WHO). WHO Information Series on School Health. Oral Health Promotion: An Essential Element of a Health-Promoting School. Geneva: World Health Organization, 2003. 2. Kwan SYL, Petersen PE, Pine CM, Borutta A. Health-promoting schools: An opportunity for oral health promotion. Bulletin of the World Health Organization. 2005;83(9):677-85. 3. Department of Health, South Africa. School Health Policy and Implementation Guidelines, 2011. www.rmchsa.org/.../SchoolHealth/ SchoolHealthPolicy&Guidelines.docx (accessed 30 April 2014). 4. Department of Health and Basic Education, South Africa. Integrated School Health Policy, 2012:1-39. www.education.gov.za/LinkClick.aspx?fileticket=pjcI v8qGMc%3D&tabid=390&mid=1125 (accessed 4 March 2013). 5. Singh S. Dental caries rates in South Africa: Implications for oral health planning. S Afr J Epidemiol Infect 2011;26(4 Part II):259-261. 6. Johnson B, Lazarus S. Building health promoting and inclusive schools in South Africa. J Prev Interv Community 2003;25(1):81-97. [http://dx.doi.org/10.1300/ J005v25n01_06] 7. Department of Health, South Africa. National Guidelines for the Development of Health Promoting Schools/Sites in South Africa (Draft 4). Pretoria: Department of Health, 2000. 8. Shasha Y, Taylor M, Dlamini S, Aldous-Mycock C. A situational analysis for the implementation of the National School Health Policy in KwaZulu-

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Natal. Dev South Afr 2011;28(2):293-303. [http://dx.doi.org/10.1080/037683 5X.2011.570077] 9. Department of Health, South Africa. National Oral Health Strategy. Pretoria: Department of Health, 2004. http://www.doh.gov.za/docs/index.html (accessed 30 April 2014). 10. Department of Health, South Africa. National Oral Health Strategy (confidential draft for comment only). 2010:1-15. 11. Department of Health, KwaZulu-Natal. Annual Report - Vote 7, 2011/2012:43. www.kznhealth.gov.za/1112report/partA.pdf (accessed 22 August 2013) 12. Department of Health, South Africa. Policy Guidelines for Youth and Adolescent Health. Pretoria: Department of Health, 2001:1-72. 13. Department of Health, South Africa. KwaZulu-Natal - Strategic Plan 2010 - 2014. 2010:68-69. www.kznhealth.gov.za/stratplan2010-14pdf (accessed 26 May 2014). 14. Singh S. A critical analysis of the provision for oral health promotion in South African Health Policy Development. PhD thesis. Cape Town: University of the Western Cape, 2005. http://etd.uwc.ac.za/xmlui/handle/11394/1960 (accessed 14 July 2012). 15. Sheiham A, Watt RG. The Common Risk Factor Approach: A rational basis for promoting oral health. Community Dent Oral Epidemiol 2000;28(6):399-406. 16. Department of Education KwaZulu-Natal. National School Nutrition Programme Policy (Draft). Pretoria: Department of Education, 2011. www. kzneducation.gov.za/Portal/O/Circuiars/General/2012/NSNP%20Draft%20 Policy20111122(1)pdf (accessed 1 November 2012). 17. Singh S, Myburgh NG, Lalloo R. Policy analysis of oral health promotion in South Africa. Glob Health Promot 2010;17(16):16-24. [http://dx.doi. org/10.1177/1757975909356631] 18. James S, Moodley V. The health of older children in a school setting. In: Health Systems Trust. South African Health Review. Durban: Health Systems Trust, 2006:283-296. 19. Edwards-Miller J, Taylor M. Making a difference to school childrenâ&#x20AC;&#x2122;s health. In: Health Systems Trust. An Evaluation of School Health Services in KwaZulu-Natal, South Africa. Durban: Health Systems Trust, 1998. www.hst.org.za/publications/ making-difference-school-childrens-health (accessed 1 November 2012). 20. Swart D, Reddy P. Establishing networks for Health Promoting Schools in South Africa. J Sch Health 1999;69(2):47-50.

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Effect of a nutrition education programme on nutritional status of children aged 3 - 5 years in Limpopo Province, South Africa L F Mushaphi,1 PhD; A Dannhauser,2 PhD; C M Walsh,2 PhD; X G Mbhenyane,3 PhD; F C van Rooyen,4 MCom Department of Nutrition, School of Health Sciences, University of Venda, Thohoyandou, South Africa Department of Nutrition and Dietetics, School of Allied Health Professions, University of the Free State, Bloemfontein, South Africa 3 Division of Human Nutrition, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa 4 Department of Biostatistics, School of Health Sciences, University of the Free State, Bloemfontein, South Africa 1 2

Corresponding author: L F Mushaphi (lindelani.mushaphi@univen.ac.za or mushaphil@gmail.com)

Background. Globally, the prevalence of chronic and acute malnutrition and micronutrient deficiency is high in young children, especially in developing countries. Nutrition education is an important intervention to address these challenges. Objective. To determine the nutritional (anthropometric and micronutrient) status of children aged 3 - 5 years at baseline and post intervention. Methods. A pre-test–post-test control group design was chosen, which included eight villages (four villages in the experimental group (E); four villages in the control group (C)). The Nutrition Education Intervention Programme (NEIP) comprised ten topics emphasising healthy eating, hygiene and sanitation. Results. At baseline, 15% (E) - 22.4% (C) of children were stunted. Very few children were underweight in both groups (E = 2.5%; C = 8.2%) and only 2.5% of children were wasted in the E group at baseline. At baseline, about a third of children in both groups (E = 38.5%; C = 30.8%) had marginal vitamin A status (100 - 199.9 µg/L), while <10% in the E group (E = 7.7%) had vitamin A deficiency (<100 µg/L). According to the categories for indicators of iron status, the number of children who were in the ‘adequate’ category for serum iron, serum ferritin, serum transferrin and percentage transferrin saturation did not change in both groups at postintervention assessment. In both groups, nutritional status of children (both anthropometric and blood variables) did not change significantly following intervention. Conclusion. The nutrition intervention did not have a significant effect on indicators of nutritional status, possibly owing to its short duration (12 months) and the fact that food supplementation was not included. S Afr J Child Health 2015;9(3)98-102. DOI:10.7196/SAJCH.7958

Globally, the prevalence of acute and chronic mal nutrition and micronutrient deficiency is high in young children, especially in developing countries, where malnutrition affects one out of every three preschool children.[1] It has been estimated that 178 million children <5 years of age suffer from chronic malnutrition. [2] According to the South African (SA) National Health and Nutrition Examination Survey (SANHANES-1),[3] children aged 0 - 3 years have the highest prevalence of stunting (26.9% for boys and 25.9% for girls). Recently, the United Nations Sub-Committee on Nutrition (UNSCN)[4] estimated that 163 million children in developing countries are vitamin A deficient. Furthermore, the Administrative Committee on Coordination/Sub-Committee on Nutrition (ACC/ SCN)[5] has calculated that more than three billion people in developing countries are iron deficient. Almost 50% of preschool children in developing countries suffer from iron-deficiency anaemia. [6] In sub-Saharan Africa, 36 million preschool children are affected by vitamin A deficiency.[7] Although the extent of clinical vitamin A deficiency in SA is not as severe as it is in some other subSaharan countries, one in three children was identified as marginally vitamin A deficient in the SA Vitamin A Consultative Group (SAVACG)[8] study, and more recent data from the SANHANES-1 indicated that 43.6% of children <5 years old in SA have vitamin A deficiency.[3] In the SAVACG[8] study, it was reported that 21% of preschool children were anaemic, while the SANHANES-1[3] found 98

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that 15.2% of young children aged 24 - 35 months and 10.9% of children aged 36 - 47 months were anaemic. Micronutrient deficiencies have a significant effect on human welfare and on the economic development of poorer countries. Micronutrient deficiencies can lead to serious health problems, including blindness, mental retardation and reduced resistance to infectious disease, and in some cases death.[9] Micronutrient deficiencies substantially affect the nutritional status, health and development of a significant percentage of the population in many countries, both developed and developing.[9] The high prevalence of micronutrient deficiencies seen in develop ing countries is mainly due to the immediate inadequate intake of dietary energy and protein, the low content of micronutrients in the diet and poor bioavailability.[10] Poor dietary intake of energy and protein and frequent infections are also associated with poor growth and development in children.[11] Furthermore, poor dietary intake and frequent infections contribute to half of all anaemia observed in children.[11] In SA, the diets given to children in most rural areas lack variety, also contributing to malnutrition. Indigenous foods can play an important role in improving dietary variety of rural populations. Therefore, the indigenous and traditional food systems of poor and rural communities need to be promoted in the search for solutions to the global problems of poverty, hunger and malnutrition.[12] According to Aphane et al.,[13] most countries are encouraged to improve the micronutrient status of the population by changing practices at the household level and by protecting the nutritional

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ARTICLE benefits of traditional practices that are eroding because of factors such as urbanisation and modernisation. When income increases, people often reduce breastfeeding, stop gathering wild foods and eat fewer green leafy vegetables owing to ignorance or poor knowledge of nutrition. Nutrition education may play an important role in improving the nutrition knowledge and the way caregivers feed their children, which could contribute to an improvement of the nutritional status of the children.

Methods

Study design

A pre-test–post-test control group design was applied. The data were collected at baseline in both the control (C) and the experimental (E) groups. After the baseline, the E group received nutrition education, while the C group did not. The intervention programme was implemented for a period of 12 months, after which anthropometric and micronutrient status were determined again.

Study population

The study population included caregivers and children aged 3 - 5 years living in Limpopo Province. For the purpose of the study, ‘caregiver’ refers to the legal guardian of the child or the mother of the child.

Sample size

Simple random sampling was used to select 8 villages (4 E, 4 C) from Mutale Municipality in Vhembe District, Limpopo, SA. All households with children who met the inclusion criteria and who agreed to participate were included in the study. A total of 129 children aged 3 - 5 years and 125 caregivers were included at baseline. Post intervention, 89 children and 86 caregivers were available to participate. This translates to a 69% response rate for both children and caregivers. Blood samples were only drawn from the children whose caregivers gave consent, resulting in low numbers.

Data collection

At baseline, four trained fieldworkers inter viewed participating caregivers, using the local language (Tshivenda), on feeding practices and nutrition knowledge. On the same day, the trained fieldworkers also took anthropometric measurements using standard procedures as described by Lee and Nieman.[14] A professional paediatric nurse was responsible for taking blood samples a few days after the interview. The blood samples were used to determine the iron and vitamin A status of the children before and after the intervention.

Nutrition Education Intervention Programme (NEIP)

The NEIP was based on the SA food-based dietary guidelines (FBDG) [15] and SA paediatric FBDG.[16] Mypyramid for children[17] and dietary guidelines for children[18] were also used. FBDG are practical and simple messages that inform the general public on which foods and eating habits will provide the nutrients they need to promote overall health and prevent chronic diseases. [15] In SA, the FBDG were developed based on affordable, available foods that are widely consumed.[15] In addition, the FBDG were compatible with different cultures and eating patterns of the target population.[15]

Implementation of the NEIP

The NEIP comprised 10 topics, namely: enjoying a variety of foods; guidelines for feeding children 3 years and older; hygiene and sanitation; making starchy foods the basis of most meals; eating plenty of vegetables and fruits every day; eating dry beans, split peas, lentils and soya; recommending that chicken, fish, meat, milk or eggs be eaten daily; using salt sparingly; eating fats sparingly; and using food and drinks containing sugar sparingly and not between meals. These were explained to the E group over a period of 12 months. The E group was visited twice a week during the implementation period. 99

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Duration of each group discussion presentation was 20 - 30 minutes. The size of the groups of caregivers during the nutrition education presentation sessions ranged from 6 to 20. The discussion approach was chosen because it promotes interaction between group members and allows caregivers to participate actively in the programme.

Data analysis

Data were analysed by the Department of Biostatistics of the University of the Free State (UFS) using Statistical Analysis Software (SAS) version 9.2 (SAS Institute Inc., USA). Continuous data were expressed using median, minimum and maximum values. Categorical data were described using frequencies and percentages, and 95% confidence intervals (CIs) were used for median and percentage differences to determine the effect of the intervention programme.

Ethical consideration

Ethical approval was obtained from the Ethics Committee of the Faculty of Health Sciences, UFS (ETOVS No. 24/06). Permission to conduct the study in the villages was obtained from local leaders. Written informed consent was obtained from caregivers.

Results

Sociodemographic data

The E and C groups were comparable at baseline in terms of sociodemographic data. In both groups, >60% of caregivers had secondary education (E = 64.6%; C = 63.3%) while 18.3% (C) - 24.6% (E) of caregivers had never attended school. In both groups the source of income was mainly the parents (E = 79.2%; C = 86.6%), while some children depended on their grandparents for support (E = 30.8%; C = 20.0%). The majority of caregivers depended on social grants (child grant: E = 75.4%, C = 78.3%; pension grant: E = 24.6%, C = 16.7%). The monthly income of 65% of households in both groups was ≤R1 000 (E = 66.2%; C = 68%). Firewood was the main source of cooking fuel (E = 98.5%; C = 95%), while electricity was available to some of the households (E = 21.5%; C = 21.7%). The main source of water was communal taps (E = 76.9%; C = 83.3%), while water from rivers (E = 32.3%; C = 31.7%) and wells (E = 35.5%; C = 8.3%) was also used. Some of the households used more than one source of water, as communal tap water was not available every day of the week.

Anthropometric status of children

Table 1 indicates that ~20% of children were stunted, 8% underweight and 5% wasted in both groups at baseline. At baseline, there were no statistically significant differences between the E and C groups regarding height for age, weight for age, height for weight and BMI/A. None of the anthropometric values changed significantly in either group after the intervention (95% CI for median difference 0 - 0). A relatively high percentage of children had a weight for age in the ‘risk for overweight’ and ‘overweight’ categories, with 21.2% in the E group and 15.8% in the C group. Less than 5% of children in both the E group and C group were wasted or severely wasted as defined by weight for height, while 4.6% of children in the E group and 4.8% in the C group were at risk of becoming overweight. The above results were confirmed by BMI/A, with very few children in both E and C groups having a low BMI/A, while ~15% in the E group and 14% in the C group were either at risk of becoming overweight or already overweight.

Micronutrient status

Very few caregivers gave consent for children’s blood samples to be taken for determining vitamin A and iron status. Hence, the micronutrients results were not compared owing to low and unequal numbers in both groups.

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ARTICLE Vitamin A status

At baseline, nearly one-third of children had marginal vitamin A status (100.0 199.9 µg/L) in both groups (E = 38.5%; C = 30.8%), 7.7% of children in the E group had vitamin A deficiency (<100 µg/L), while in the C group no low vitamin A values were detected (Table 2). Before intervention more than 50% of children had an adequate vitamin A status and after intervention, the majority of children in the E and the C groups had a normal to well-nourished vitamin A status.

Iron status

According to the categories for indicators of iron status, the number of children who were in the ‘adequate’ categories for serum iron, serum ferritin, serum transferrin and percentage transferrin saturation did not change in either group following the intervention (Table 3). As far as iron status was concerned, all of the parameters of iron status in both groups indicated that the majority of children had adequate iron status both pre and post intervention.

Discussion

High levels of poverty were evident in the participants as indicated by the majority of caregivers being unemployed and relying on child support grants for income, which could have had a negative effect on nutritional status of the children. In contrast, Smuts et al.[20] showed that much lower numbers of households depend on child support grants for their income in rural areas of the Eastern Cape and KwaZulu-Natal Provinces compared with our results. In a study done in rural localities of North-West Ethiopia, preschool children who belonged to families with low income were at greater risk of being wasted, underweight and stunted.[21] Another factor possibly contributing to the high poverty levels observed in the current study could be the high level of illiteracy (17% of caregivers), which is comparable with other studies conducted in SA[3] and rural Uganda.[22] A low literacy rate can contribute to caregivers getting lowpaying jobs, resulting in low income when compared with their counterparts. In the current study, nearly one-third of households were getting water from the river, a borehole or a well. Matthews et al.[23] indicated that in underdeveloped areas of North-Western Nigeria, the common sources of drinking water were rivers or lakes (24%), private wells (23%), taps inside the house (18.7%) and boreholes (14.1%). The main source of drinking water in the rural districts of KwaZulu-Natal and Eastern Cape was a river (50% and 76%, respectively). [20] A considerable number of people in low socioeconomic rural areas still do not have

Table 1. Z-score classification of HAZ, WAZ, WHZ and BMI/A at baseline[19] Interpretation

E group C group (N=66), % (N=63), %

95% CI for median difference

<–3SD

Severely stunted

4.6

1.6

0-0

–3SD - <–2SD

Stunted

15.2

19.4

0-0

–2SD - <–1SD

Mildly stunted

–1SD - +1SD

Normal height

53.0

48.4

0-0

>+1SD - ≤+2SD

Normal height

27.3

30.7

0-0

<–3SD

Severely underweight

1.5

0-0

–3SD - <–2SD

Underweight

6.1

8.0

0-0

–2SD - <–1SD

Mildly underweight

–1SD - +1SD

Normal WAZ

71.2

76.2

0-0

>+1SD - ≤+2SD

Possible growth problem

19.7

11.0

0-0

>+2SD - ≤+3SD

Possible growth problem

1.5

4.8

0-0

<–3SD

Severely wasted

1.5

0-0

–3SD - <–2SD

Wasted

3.0

4.8

0-0

–2SD - <–1SD

Mildly wasted

–1SD - +1SD

Normal WHZ

87.9

88.8

0-0

>+1SD - ≤+2SD

Possible risk of overweight

4.6

4.8

0-0

>+2SD - ≤+3SD

Overweight

3.0

1.6

0-0

Z-score classification HAZ WHO classification

WAZ WHO classification

WHZ WHO classification

BMI/A z-score WHO classification <–3SD

Severely wasted

1.5

0-0

–3SD - <–2SD

Wasted

3.0

0-0

–2SD - <–1SD

Normal

–1SD - +1SD

Normal BMI/A

80.3

85.7

0-0

>+1SD - ≤+2SD

Possible risk of overweight

9.1

12.7

0-0

>+2SD - ≤+3SD

Overweight

6.1

1.6

0-0

HAZ = height-for-age z-score; WAZ = weight-for-age z-score; WHZ = weight-for-height z-score; BMI/A = body mass index for age; WHO = World Health Organization; SD = standard deviation.

Table 2. Vitamin A status of children at baseline and post intervention E group

C group

Serum vitamin A concentration categories

Baseline, % (N=13)

Post, % (N=23)

Baseline, % (N=26)

Post, % (N=38)

Vitamin A deficiency

<100 µg/L

7.7

Marginal vitamin A status

100 - 199.9 µg/L

38.5

30.8

Adequate status

200 - 299.9 µg/L

53.9

30.4

53.9

5.3

Normal/wellnourished status

≥300 µg/L

69.6

15.4

94.7

Serum vitamin A categories

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ARTICLE Table 3. Iron status children 3 - 5 years, pre and post intervention E group Iron indicators

C group

Serum concentration

Baseline (N=17), %

Post (N=29), %

Baseline (N=26), %

Post (N=40), %

Depletion

<5.0 µmol/L

5.9

3.5

2.5

Adequate

5.0 - 16.7 µmol/L

88.2

75.9

88.5

65.0

High

>16.7 µmol/L

5.9

20.7

11.5

32.5

Adequate

7 - 140 ng/mL

100

96.6

96.2

100

High

>140 ng/mL

3.5

3.9

Adequate

1.5 - 3.5 g/L

94.1

96.6

100

97.5

High

>3.5 g/L

5.9

3.5

2.5

Low

<17%

5.9

3.5

2.5

Adequate

17 - 42%

94.1

96.6

100

95.0

High

>42%

2.5

Serum iron

Serum ferritin

Serum transferrin

Transferrin saturation

access to clean, safe water, as they still use water from rivers, dams or lakes. In the current study, stunting, underweight and wasting (95% CI 0 - 0) did not change in either group after implementation of the NEIP, which was implemented for a period of 1 year. A similar observation was made in the study undertaken in the capital city of Anhui Province in China, where height for age and weight for age did not improve significantly after implementation of a nutrition education intervention that was implemented for 1 year by trained nutrition graduates and research assistants.[24] Contrary to these findings, Ghoneim et al.[25] found that the number of children aged 2 - 5 years from three daycare centres in Alexandria, Egypt, who were stunted and wasted decreased significantly after 1 year of implementing health education among the parents. The most obvious reason for the marked improvement in the study by Ghoneim et al.[25] was the provision of two meals and fruit snacks per day. The NEIP in this present study was implemented by one person over a period of 1 year, while the study by Ghoneim et al.[25] included higher coverage since it was implemented by two or more people over 2 years. In addition, the current study did not include food supplementation. Before intervention, more than 50% of children had an adequate vitamin A status; after intervention, the majority of children in both the E and C groups had a normal to good vitamin A status. The national vitamin A supplementation programme that was implemented at the same time as this intervention may have affected vitamin A levels, and this is most probably the reason why improvement occurred in both the E and C groups. As far as iron status was concerned, all of the parameters of iron status indicated that the majority of children had adequate iron status, even before intervention. The national food fortification programme could possibly have had an effect on the results. Furthermore, because the sample of children on which blood could be drawn was so small, these results should be interpreted with caution.

Conclusions

The NEIP did not have a significant effect on anthropometric nutritional status and micronutrient status of children, as there was no change observed in these parameters after intervention. Lack of 101

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improvement may be attributed to the fact that the majority of children had normal nutritional status (anthropometric and micronutrient) at baseline, leaving little room for improvement. The relatively short intervention period could also not have allowed enough time for significant physiological change in nutritional status to occur.

Recommendations

The NEIP developed in the present study can be adapted to include the use of media that can increase coverage. Future studies should develop nutrition intervention strategies only after the collection of baseline data in order to address the identified needs of the community being studied. Acknowledgements. We would like to thank the National Research Foundation, the University of Venda and the Department of Science and Technology for funding the project.

References 1. United Nations Standard Committee on Nutrition (UNSCN). Fifth Annual Report on the World Nutrition Situation: Nutrition for improved development outcomes. Sudbury, UK: Lavenham Press, 2004. 2. UNSCN. Tackling the Double Burden of Malnutrition: A Global Agenda. SCN News, Number 32 mid-2006. Sudbury, UK: Lavanham Press, 2006. 3. Shisana O, Labadarios D, Rehle T, et al. South African National Health and Nutrition Examination Survey (SANHANES-1). Cape Town: HSRC press, 2013. 4. UNSCN. Sixth Report on the World Nutrition Situation. Progress in Nutrition. Sudbury, UK: Lavanham Press, 2011. 5. United Nations Administrative Committee on Coordination Sub-Committee on Nutrition (ACC/SCN) in collaboration with International Food Policy Research International (IFPRI) United Nations, Geneva. Fourth Report on the World Nutrition Situation: The World Nutrition Situation. Nutrition Throughout the Life Cycle. Geneva: ACC/SCN, 2000. 6. United Nations Children’s Fund (UNICEF), United Nations University (UNU), World Health Organization (WHO). Iron Deficiency Anaemia – Assessment, Prevention and Control: A Guide for Programme Managers. Geneva: WHO, 2001. 7. Begin F, Greig A. Food Fortification in West Africa: Assessment of Opportunities and Strategies. Ottawa, USA: Micronutrient Initiative, 2002. 8. The South African Vitamin A Consultative Group (SAVACG); Labadarios D, van Middelkoop A, eds; and assisted by Coutsoudis A, Eggers RR, Hussey G, Jsselmuiden G, and Kotz JP. Children Aged 6 to 71 months in South Africa, 1994: Their Anthropometric, Vitamin A, Iron and Immunization Coverage Status. Johannesburg: SAVACG, 1995. 9. Food and Agriculture Organization (FAO). Community-based Food and Nutrition Programmes: What Makes Them Successful. A Review and Analysis of Experience. Rome: FAO United Nations, 2003:47.

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ARTICLE 10. Rivera JA, Hotz C, Gonzalez-Cossio T, Neufeld L, Garcia-Guerra A. The effect of micronutrients deficiencies on child growth: A review of results from community-based supplementation trials. J Nutr 2003;133 (11 Suppl 2):S4010-S40120. 11. WHO; de Benoist B, Mclean E, Egli I, Cogswell M, eds. Worldwide Prevalence of Anaemia 1993 - 2005: WHO Global Database on Anaemia. Geneva: WHO, 2008. 12. Faber M, Wenhold F. Nutrition in contemporary South Africa. Water SA 2007;33(3). http://www.wrc.org.za (accessed 20 June 2010). 13. Aphane J, Chadha ML, Oluoch MO. Increasing the Consumption of Micronutrient-rich Foods Through Production and Promotion of Indigenous Foods. FAO-AVRDC International workshop proceedings, Arusha, Tanzania. Rome: FAO United Nations, 2003. 14. Lee RD, Nieman DC. Nutritional Assessment. 4th ed. New York: Mcgraw-Hill companies, 2007. 15. Voster HH, Love P, Browne C. Development of food-based dietary guidelines for South Africa: The process. S Afr J Clin Nutr 2001;14(3):S3-S6. 16. Bourne LT. South African paediatric food-based dietary guidelines. Matern Child Nutr 2007;3(4):227-229. [http://dx.doi.org/10.1111/j.17408709.2007.00107.x] 17. Smolin LA, Grosvenor MB. Nutrition: Science and Applications. New York: John Wiley and Sons Inc., 2008.

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18. Burgess A, Glasauer P. Family Nutrition Guide. Rome: FAO United Nations, 2004. 19. WHO. WHO AnthroPlus for Personal Computers Manual, Software for Assessing Growth of the Worldâ&#x20AC;&#x2122;s Children and Adolescents. Geneva: WHO, 2009. 20. Smuts CM, Faber M, Schoeman SE, et al. Socio-demographic profiles and anthropometric status of 0 to 71 month-old children and their caregivers in rural districts of Eastern and Kwa-Zulu Natal provinces of South Africa. S Afr J Clin Nutr 2008;21(3):117-124. 21. Edris M. Assessment of nutritional status of pre-school children of Gumbrit, North West Ethiopia. Ethop J Health Dev 2007;21(2):125-129. 22. Wamani H, AstrĂ¸m AN, Peterson S, Tumwine JK, Tylleskar T. Predictors of poor anthropometric status among children under 2 years of age in rural Uganda. Public Health Nutr 2006;9(3):320-326. 23. Matthews AK, Amodu AD, Sani I, Solomon SD. Infant feeding practices and nutritional status of children in North Western Nigeria. Asian J Clin Nutr 2009;1(1):12-22. 24. Hu C, Ye D, Li Y, Huang Y, Gao Y, Wang S. Evaluation of a kindergarten-based nutrition education for pre-school children in China. Public Health Nutr 2009;13(2):253-260. [http://dx.doi.org/10.1017/S1368980009990814] 25. Ghoneim EH, Hassan MHA, Amine EK. An intervention programme for improving the nutritional status of children aged 2 to 5 years in Alexandria. Eastern Mediterr Health J 2004;10(6):828-843.

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CASE REPORT

Food allergy: Two case reports and management challenges in a resource-limited setting O F Adeniyi,1 MBBS, FMC (Paed), MSc (Child Health); J K Renner,2 MBBS, FWACP 1 2

Department of Paediatrics, College of Medicine, University of Lagos; and Lagos University Teaching Hospital, Lagos, Nigeria Department of Paediatrics, College of Medicine, Babcock University, Sagamu, Ogun State, Nigeria

Corresponding author: O F Adeniyi (layo_funke@yahoo.co.uk)

Background. Food allergy has been well described in white children, and cow’s milk protein allergy (CMPA) still remains the most common allergy in these children. Information on the same subject in developing countries is very limited, and management of this condition remains challenging. Case presentation. We report on two cases of children with multiple food allergies. The first patient presented with chronic diarrhoea following the introduction and use of several infant formulas, while the second patient had more severe allergic reactions following ingestion of milk, egg and wheat. Elimination of identified triggers from the diet resulted in significant clinical recovery in both cases. Conclusion. Food allergy, especially CMPA, should be considered more frequently in infants and children from developing countries, especially when there is a significant reaction to the introduction of cow’s milk. A high index of suspicion and appropriate laboratory support are also needed in the diagnosis and management of other food allergies in the African setting. S Afr J Child Health 2015;9(3):103-104. DOI:10.7196/SAJCH.8152

Multiple food allergies have been well described in developed countries; making a diagnosis and sub sequent management in these countries where the facilities are readily available is relatively easy. [1-3] Cow’s milk protein allergy (CMPA) remains the most common food allergy in these countries.[2,3] Many primary care physicians in developing countries are still unaware of the condition, especially in sub-Saharan Africa, where it may be misdiagnosed as food poisoning, infective diarrhoea or even lactose intolerance. Most children with vomiting, diarrhoea or other foodrelated symptoms are given antibiotics either at home or by some physicians before being referred for any specialist care. In many developing countries, there is a paucity of data on food allergy, and diagnosis and management of this condition is still very challenging due to its variable clinical presentation. We report two cases of children with multiple food allergies, with variable clinical presentation, and highlight the challenges in managing cases of food allergy in the African setting.

uncle and allergic conjunctivitis in the paternal grandmother. The patient was the only child of a monogamous family. Physical examination was normal and anthropometry was as follows: weight 7.2 kg (15th percentile), length 68 cm (50th percentile) and occipito frontal circumference 45 cm (85th percentile). A tentative diagnosis of CMPA was made. Investigations requested, namely skin prick tests and IgE levels, were not done owing to financial constraints and unavailability of the reagents for the skin prick tests in the hospital at the time. Cow’s milk was excluded from the diet and an extensively hydrolysed formula (EHF) preparation (Pepti Junior, Cow & Gate, UK) was subsequently introduced. After about 2 weeks, the passage of loose stools and blood-streaked stools resolved. The child thrived subsequently and follow-up by the 2nd birthday showed that the patient weighed 12 kg. Following the 2nd birthday i.e. the 3rd year of life, the EHF was discontinued and cow’s milk was gradually introduced into the diet. Symptoms never reoccurred and she currently eats all food, including eggs.

Case presentation 1

Case presentation 2

OC, a female infant, was first seen at the age of 8 months on account of recurrent loose stools for 2 months. Stools were non-mucoid, but there was a history of occasional bloody streaks in the stools. There was no associated vomiting or fever. Each episode of loose stools was precipitated by ingestion of formula milk feeds. Infant formula was introduced initially at the age of 1 month, but the patient had a similar reaction to the use of three different formulas. There was also a similar reaction to ingestion of eggs. She had a course of metronidazole with each episode of the bloody stools, with no improvement. An initial diagnosis of lactose intolerance was suggested to the mother (this was not confirmed by laboratory tests) and thus at the age of 5 months, a soy-based formula was introduced; however, there was no appreciable improvement of symptoms. At presentation, the patient was on fortified maize cereal with soy-based milk, peanuts and margarine, and mashed potatoes with fish. The rest of the history was unremarkable except for allergic rhinitis in the mother, atopical dermatitis and asthma in the maternal 103

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The second case, JI, a 16-month-old female child, was referred from a private children’s hospital on account of allergic reaction to infant formula and eggs. She was the product of a normal, full-term pregnancy and weighed 3.3 kg at birth. On the first day of life, JI was given Nan (Nestlé, Australia) formula as the mother was not yet lactating well, but she developed generalised body rash and the formula was discontinued. The mother was able to exclusively breastfeed for 2 months, and by the 3rd month of age another infant formula was introduced (SMA Gold, SMA, UK); however, again she developed a body rash, and facial and abdominal swelling. Subsequently, she had similar reactions when eggs, fish and wheat were introduced, and had recurrent reactions whenever she was given any of these foods. The mother had also noticed that she was gaining weight poorly. A month prior to presentation, she developed vomiting, diarrhoea and abdominal distension with excessive flatulence within 2 hours of feeding. The mother had given metronidazole and ampiclox before presentation at the hospital. The patient’s paternal uncle was a known asthmatic.

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CASE REPORT Significant findings on physical examination revealed a malnourished child, pale with sparse, fluffy hair, with no oedema. Her weight was 7.1 kg which is <5th percentile and length 68 cm, which was also <5th percentile. Weight for length was similarly <5th percentile. Systemic examination was normal. An assessment of failure to thrive secondary to food allergy (CMPA) to rule out gluten sensitivity was made. The results of the investigation revealed that the radio-allergosorbent test (RAST) was positive for egg white f1, milk f2, codfish f3, wheat f4, peanut f13 and soya bean f14. The tissue trans glutaminase (TTG) antibody test and endomysial antibodies (TTG IgA-0.30(0-10), TTG IgG-0.9(010); endomysium IgA) were negative. Serum proteins were within normal limits. Cow’s milk was eliminated from the diet and an EHF was introduced, but the patient did not tolerate this. She ultimately tolerated an amino acid-based formula (Neocate Active, Nutricia, UK) courtesy of some relatives in the UK and USA who were able to help procure the formula. However, this was an expensive therapy as each pack of this formula cost about NGN20 000 (USD120) and the recommendation is for at least two packs/day. Within a month of commencement of the formula, the patient’s symptoms resolved. Eggs, wheat and fish were then reintroduced, which she now tolerates. However, at 24 months of age when cow’s milk was reintroduced, she still reacted to it and therefore she is currently still on Neocate formula with rational use. She is also receiving the recommended daily allowance for supplements, namely vitamins A, D and B complex and calcium, and during follow-up visits she has been observed to be thriving.

Discussion

In our first case diagnosis of possible infantile CMPA was made based solely on history, physical examination and the positive response to a dietary elimination trial. The diagnostic workup was significantly limited by the financial constraints of the parents, unwillingness to carry out other confirmatory tests and unavailability of local resources for the tests. A more thorough laboratory work-up a with skin prick test, RAST and IgE tests could have supported the diagnosis more firmly.[4-6] Nevertheless, the patient still had significant symptoms suggestive of the condition; it has been observed in some studies that 18% of children with blood in their stools had CMPA.[7] The failure of improvement of symptoms following the use of soy-based formula is not surprising as up to 10 - 14% of CMPA patients also cross-react to soy protein, especially infants <6 months of age.[8.9] The use of antibiotics in many developing countries remains questionable in patients who present with gastroenteritis. This is a result of lack of appropriate laboratory support in making a diagnosis, especially in rural areas. It appears that many cases of vomiting or diarrhoea, which may occur as a symptom of food allergy, are believed to be of infective origin and thus children have often had a course of antibiotics before presentation at hospital. The second case illustrates a more severe clinical manifestation of food allergy, which has been reported by other authors.[10] Although the confirmatory tests were done in this instance because of willing parents, the affordability and sustainability of the amino acid formula has been very challenging to the family. This demonstrates the plight of average citizens in the African setting who may not be able to afford such an expensive therapy for their children. These two cases

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highlight the variable presentation of multiple food allergies. The reason for allergy to multiple foods may be explained by possible cross-reactivity of the allergens.[10] In most cases, the children become desensitised by the age of 2 years and most will outgrow the allergies, as occurred with the first case in this study. However, there lies the possibility of development of other allergic conditions, namely allergic conjunctivitis, rhinitis or asthma in the future and therefore the parents were duly counselled about this. Challenges in the management of food allergy in the African setting are numerous, namely misdiagnosis, late presentation, and unavailability of diagnostic facilities and appropriate substitution diet. Therefore, a high index of suspicion is important in resourcelimited countries where confirmatory tests cannot be carried out. Eliminating the offending food from the diet and subsequent resolution of symptoms can help to confirm the diagnosis. It has been suggested that in tribes/ethnic groups where cow’s milk is given to young infants for nutritional purposes or cultural reasons and the children develop gastrointestinal symptoms or other clinical manifestation, the possibility of CMPA should be entertained.[11] Currently, it has been suggested that a supervised food challenge be performed after a few weeks of elimination diet and gradual reintroduction be done between 9 months and 18 months of age depending on the severity of the allergic reaction.[10,11]

Conclusion

Clinicians working in resource-limited countries need to be aware of and have a high index of suspicion of food allergy, especially CMPA, when the history and clinical findings are suggestive. A therapeutic elimination diet should be commenced, and substitution therapy with the appropriate formula in the case of CMPA, if affordable, should be instituted. References 1. Minford AMB, Macdonald A, Littlewood JM. Food intolerance and food allergy in children: A review of 68 cases. Arch Dis Child 1982;57(10):742-747. 2. Sicherer SH. Epidemiology of food allergy. J Allergy Clin Immunol 2011;127(3):594-602. [http://dx.doi.org/10.1016/j.jaci.2010.11.044] 3. Rona RJ, Keil T, Summers C, et al. The prevalence of food allergy: A metaanalysis. J Allergy Clin Immunol 2007;120(3):638-646. [http://dx.doi. org/10.1016/j.jaci.2007.05.026] 4. Huang J, Walker WA. Review of pediatric gastrointestinal disease and nutrition. London: BC Decker, 2005. 5. Vandenplas Y, Koletzko S, Isolauri E, et al. Guidelines for the diagnosis and management of cow’s milk protein allergy in infants. Arch Dis Child 2007;92(10):902-908. [http://dx.doi.org/10.1136/adc.2006.110999] 6. Eigenmann PA. The spectrum of cow’s milk allergy. Pediatr Allergy Immunol 2007;18(3):265-271. [http://dx.doi.org/10.1111/j.1399-3038.2006.00528.x] 7. Arvola T, Ruuska T, Keränen J, Hyöty H, Salminen S, Isolauri E. Rectal bleeding in infancy: Clinical, allergological, and microbiological examination. Pediatrics 2006;117(4):760-768. [http://dx.doi.org/10.1542/peds.2005-1069] 8. Klemola T, Vanto T, Juntunen-Backman K, et al. Allergy to soy formula and to extensively hydrolyzed whey formula in infants with cow’s milk allergy: A prospective, randomized study with a follow-up to the age of 2 years. J Pediatr 2002;140(@):219-224. [http://dx.doi.org/10.1067/mpd.2002.121935] 9. Zeiger RS, Sampson HA, Bock SA, et al. Soy allergy in infants and children with IgE-associated cow’s milk allergy. J Pediatr 1999;134(5):614-622. 10. Koletzko S, Niggemann YB, Arato ZA, et al. Diagnostic approach and management of cow’s-milk protein allergy in infants and children: ESPGHAN GI Committee practical guidelines. J Pediatr Gastroenterol Nutr 2012;55(2):221229. [http://dx.doi.org/10.1097/MPG.0b013e31825c9482] 11. Krüger C, Malleyeck I. Diagnosing possible infantile cow’s milk protein allergy in rural Africa, when history and physical examination are the only tools: A case report. Cases J 2009;2:6287. [http://dx.doi.org/10.4076/1757-1626-2-6287]

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CPD August 2015 The CPD programme for SAJCH is being administered by Medical Practice Consulting: CPD questionnaires must be completed online at www.mpconsulting.co.za

True (T) or False (F): Regarding chronic lung disease in HIV-infected children 1. The respiratory rate ratio is the ratio obtained by comparing the respiratory rate with the mean of normal for age. 2. In adolescents with chronic lung disease, obliterative bronchiolitis with concomitant bronchiectasis is the most common pathological abnormality. 3. Most HIV-infected children with chronic lung disease are responsive to bronchodilators. Regarding severe pneumonia in HIV-exposed or infected infants 4. The two most common infective agents in HIV-infected infants with severe pneumonia requiring ventilation are Pneumocystis jiroveci and cytomegalovirus. 5. Hospital mortality among HIV-infected infants with severe pneumonia and requiring ventilation is >25%. Regarding autism in children 6. Autism spectrum disorder (ASD) is characterised by difficulty in social communication, language and related cognitive skills. 7. ASD cannot be classified as a disability as it does not meet the criteria delineated by the International Classification of Functioning, Disability and Handicap. Regarding HIV disclosure to children on highly active antiretroviral therapy (HAART) 8. The majority of children between 8 and 14 years who had been on HAART for >1 year had had their HIV status disclosed to them. 9. The better educated the caregiver, the more likely disclosure will have occurred. 10. It is estimated that ~2.4% of children in South Africa between 1â&#x20AC;&#x201A; and 14 years are HIV-infected.

Regarding the use of case management guidelines of IMCI by health workers in Tshwane 11. The majority of patients 2 - 60 months old referred to a regional hospital had been appropriately assessed using IMCI guidelines by the referring clinic healthcare workers. 12. Nutrition and immunisation status should be checked at each clinic visit. 13. At each consultation, the healthcare worker should inquire about the following four symptoms: cough or difficulty in breathing, diarrhoea, fever and ear problems. Regarding oral health promotion services in KwaZulu-Natal schools 14. Less than half of Health Promoting Schools had oral health promotion services in place. 15. Most schools in South Africa are classified as Health Promoting Schools. Regarding the effect of a nutrition education programme on the nutritional status of young children 16. Stunting occurs in ~20% of children between 2 and 5 years of age. 17. Underweight for age occurs in ~10% of children between 2 and 5 years of age. 18. A nutrition education programme conducted over 12 months had no effect on micronutrient deficiency of young children. Regarding food allergy 19. Allergy to peanuts is the most common food allergy in young children. 20. Cowâ&#x20AC;&#x2122;s milk protein allergy may present with bloody stools and proctocolitis in infants.

A maximum of 3 CEUs will be awarded per correctly completed test. CPD questionnaires must be completed online via www.mpconsulting.co.za. After submission you can check the answers and print your certificate. Accreditation number: MDB015/165/02/2015(Clinical)

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