Children caught in the long shadow of COVID-19

Despite the more transmissible delta variant being associated with higher rates of COVID-19 in unvaccinated adolescents, children have remained relatively spared from severe disease. Nevertheless, children are indirectly affected by the COVID-19 pandemic, which threatens to have far-reaching consequences. The effect of disruptions of seasonal patterns of circulation of respiratory pathogens on future immunity against such pathogens, childhood immunization programmes, and HIV and tuberculosis treatment programmes poses a threat to the future wellbeing of children. Furthermore, the economic devastation caused by the pandemic, including an increase in unemployment, gives rise to numerous challenges, such as food insecurity, which is likely to worsen childhood nutritional status. Also, COVID-19 has ongoing effects on the mental wellbeing of children, driven in part by the interruption of schooling and other opportunities to socialize. An increase in psychological illnesses has manifested in children consequent to the stresses of the pandemic, lockdowns, caregiver deaths. In this article, we highlight the indirect effects of COVID-19 on children, and suggest solutions to mitigate against the long-term sequelae. A focused health, nutrition, education and child protection response is required from government and healthcare practitioners to safeguard the health and wellbeing of South African children.

Child health, infant formula funding and South African health professionals: Eliminating conflict of interest.

Letters by Van Niekerk and Khan on article by Lake et al. (Lake L, Kroon M, Sanders D, et al. Child health, infant formula funding and South African health professionals: Eliminating conflict of interest. S Afr Med J 2019;109(12):902-906. https://doi.org/10.7196/SAMJ.2019.v109i12.14336); and response by Lake et al.

Child health, infant formula funding and South African health professionals: Eliminating conflict of interest.

Despite clear evidence of the benefits of exclusive and continued breastfeeding for children, women and society, far too few children in South Africa (SA) are breastfed. One of the major impediments to improving this situation is the continued and aggressive marketing of breastmilk substitutes (BMSs) and infiltration of the BMS industry into contexts with exposure to health professionals. In this article we, as academics, practitioners and child health advocates, describe contraventions of the regulations that protect breastfeeding in SA and argue that bold, proactive leadership to eliminate conflict of interest in respect of the BMS industry is urgently required, together with far greater investments in proven interventions to promote and support breastfeeding.

Early life risk exposure and stunting in urban South African 2-year old children.

Stunting is a measure of overall nutritional status and is a major public health concern because of its association with child mortality and morbidity and later adult performance. This study examined the effects of pregnancy events, birth characteristics and infant risk exposure on stunting at age 2 years. The study, established in 1990 in Soweto, an urban South African township, included 1098 mother-infant pairs enroled in the Birth to Twenty Plus longitudinal birth cohort study. In total, 22% of children were stunted at age 2 years, with males at greater risk than females [24.8 v. 19.4%, odds ratio (OR)=1.38; 95% confidence interval (CI): 1.03, 1.83]. In unadjusted analysis, male sex, household socio-economic status (SES), overcrowding, maternal age, maternal education, single motherhood, ethnicity, birth weight, gestational age and duration of infant breastfeeding were all significantly associated with stunting. In multivariable analysis, higher birth weight was protective against stunting for both sexes. Higher maternal education was protective for females only (adjusted odds ratio (AOR)=0.35; 95% CI: 0.14, 0.87), whereas wealthier household SES protected males (AOR for richest SES group=0.39; 95% CI: 0.16, 0.92). In this and other similar settings, current stunting prevention efforts focussing on primarily providing targeted proximal interventions, such as food supplements, risk undermining the critical importance of addressing key distal determinants of stunting such as SES and maternal education.

Infant Feeding Practices in a High HIV Prevalence Rural District of KwaZulu-Natal; South Africa

Aim: To describe infant feeding practices at birth and at 14 weeks post-partum in the Ugu-North Health District; KwaZulu-Natal; South Africa. Methods: A prospective; cohort study design was used. Mothers who delivered over a one-month period were interviewed at birth and 14 weeks later. Results: Initially; 168 mothers were interviewed within 24 hours of delivery; of whom 117 (70) were contactable at 14 weeks post-partum. The vast majority (96) initiated breast-feeding at birth. At birth; less than one-third (55/168 [32.7]) of mothers declared an intention to both breast and formula (mix) feed in the next 14 weeks; but by the 14th week post-partum over three-quarters (89/117 [76.1]) actually practised mixed feeding. At 14 weeks; the prevalence of exclusive breast-feeding was 18: 52of infants were offered water and 73solids. The majority (20/23 [87]) of HIV infected mothers chose to breastfeed their infants at birth. Nevertheless; they were significantly more likely to formula feed their infants compared to HIV negative mothers (3/23 [13.0] vs 2/145 [1.4]; OR 10.73; 95CI 1.34 - 99.16; p = 0.02). By 14 weeks; only 11of HIV positive mothers were still exclusively breast-feeding; while almost two-thirds (12/19 [63]) practised mixed feeding. This change was mainly ascribed to their need to return to school (40) or to work (20). Conclusions: Most infants were fed inappropriately by 14 weeks of age. The failure to maintain exclusive breast-feeding; despite high initiation rates; is of greatest concern. Routine prevention of mother-to-child transmission of HIV services was ineffective in influencing mothers to follow any feeding regimen exclusively

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

BACKGROUND: Childhood disability in South Africa has failed to receive adequate attention from governmental agencies, such as the health, education and social welfare departments, despite there being more than 1 million disabled children in the country. This study sought to assess the unmet rehabilitation, education and welfare needs of disabled children living in a peri-urban township. METHODS: As no register of disabled children existed, snowball sampling was used to recruit a convenience sample of 156 disabled children living in Orange Farm township near Soweto, South Africa. Children's impairments, their health and educational needs, and the availability and utilization of services were assessed using a structured interview. RESULTS: Few disabled children attended pre-school (35%) or school (44%). Only a quarter (26%) of children in need of rehabilitation received such services. Children with motor impairments were more likely to receive rehabilitation than those with intellectual impairment (44% vs. 8%, P < 0.0001). Of the 233 assistive devices required, only 64 (28%) had been issued. Less than half (45%) of the children entitled to a social assistance grant were receiving it. Lack of money, limited awareness about available services, and bureaucratic obstacles were the main reasons offered by caregivers for the low utilization of available services and resources. CONCLUSION: Children with disabilities living in Orange Farm are not enjoying the rights and services to which they are entitled. Innovative, co-ordinated service delivery strategies, and better-informed caregivers combined with community recognition of, and support for, the needs of disabled children are required to address these unmet needs.

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

BACKGROUND: Early onset bacterial infection is an important cause of morbidity and mortality in newborn infants. Various factors that increase the risk of neonatal infection have been identified. It is unclear whether asymptomatic newborn infants born to mothers with one or more of these risk factors should receive antibiotics prophylactically rather than selectively if only clinical or microbiological evidence of sepsis emerges. OBJECTIVES: To assess the effect of prophylactic versus selective antibiotic treatment for asymptomatic term neonates born to mothers with risk factors for neonatal infection. SEARCH STRATEGY: We used the standard methods of the Cochrane Neonatal Review Group. We searched MEDLINE (1966 - May 2004), EMBASE (1980 - May 2004), LILACS (1982 - 2003), SciELO (1997 - 2003), the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2004), and Centers for Disease Control and Prevention protocols and guidelines on the subject. SELECTION CRITERIA: Randomized controlled trials, or trials using quasi-random methods of allocation, comparing the use of prophylactic versus selective antibiotics in asymptomatic neonates born to mothers with one or more risk factors for infection. DATA COLLECTION AND ANALYSIS: We extracted the data using the standard methods of the Cochrane Neonatal Review Group, with separate evaluation of trial quality and data extraction by three reviewers and synthesis of data using relative risk and risk difference. The pre-specified primary outcomes were neonatal mortality, systemic neonatal infection, and need for admission to a neonatal intensive care unit. MAIN RESULTS: We identified two small trials undertaken in the 1970s. Both trials had methodological weaknesses. There was no evidence of an effect on any of the primary outcomes, but because the trials were underpowered, clinically important effect sizes may have been missed. REVIEWERS' CONCLUSIONS: There are insufficient data from randomized controlled trials to guide clinical practice. A large randomized controlled trial is needed in asymptomatic term infants born to mothers with risk factors for infection in their babies, which compares the effect of prophylactic versus selective antibiotics on morbidity, mortality and costs.

Anti-inflammatory treatment for carditis in acute rheumatic fever.

BACKGROUND: Rheumatic heart disease remains the most important cause of acquired heart disease in developing countries. Although the prevention of rheumatic fever and the management of recurrences is well established the optimal management of active rheumatic carditis is still unclear. OBJECTIVES: To assess the effects of anti-inflammatory agents such as aspirin, corticosteroids and immunoglobulin for preventing or reducing further heart valve damage in patients with acute rheumatic fever. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register (Issue 4, 2000), MEDLINE (1966 to April 2002), EMBASE (1998 to November 2002), LILACS (1998 to November 2002), Index Medicus (1950 to December 2000) and references lists of identified studies. SELECTION CRITERIA: Randomised controlled trials comparing anti-inflammatory agents (e.g. aspirin, steroids, immunoglobulins) with placebo or controls, or comparing any of the anti-inflammatory agents with one another, in patients with acute rheumatic fever diagnosed according to the Jones, or modified Jones criteria. The presence of cardiac disease one year after treatment was the major outcome criteria selected. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted data and assessed trial quality. MAIN RESULTS: Eight randomised controlled trials involving 996 people were included. Several steroidal agents viz. ACTH, cortisone, hydrocortisone, dexamethasone and prednisone, and intravenous immunoglobulin were compared to aspirin, placebo or no treatment in the various studies. Six of the trials were conducted between 1950 and 1965, whilst the remaining two were done in the last 10 years. Overall there was no significant difference in the risk of cardiac disease at one year between the corticosteroid-treated and aspirin-treated groups (relative risk 0.87, 95% confidence interval 0.66 to 1.15). Similarly use of prednisone (relative risk 1.78, 95% confidence interval 0.98 to 3.34) or intravenous immunoglobulins (relative risk 0.87, 95%confidence interval 0.55 to 1.39) when compared to placebo did not reduce the risk of developing heart valve lesions at one year. REVIEWER'S CONCLUSIONS: There is no benefit in using corticosteroids or intravenous immunoglobulins to reduce the risk of heart valve lesions in patients with acute rheumatic fever. The antiquity of most of the trials restricted adequate statistical analysis of the data and acceptable assessment of clinical outcomes by current standards. New randomised controlled trials in patients with acute rheumatic fever to assess the effects of corticosteroids such as oral prednisone and intravenous methylprednisone, and other new anti-inflammatory agents are warranted. Advances in echocardiography will allow for more objective and precise assessment of cardiac outcomes.

The health professional's role in preventing nosocomial infections.

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

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

OBJECTIVES: To examine changes in survival rates among low-birth-weight (LBW) infants between the years 1950 and 1996. METHODS: Survival figures were analysed for LBW infants managed at Baragwanath Hospital, a tertiary care centre in Soweto, Johannesburg, over four periods spanning five decades. RESULTS: The overall mortality rates of LBW infants decreased markedly between the early 1950s and the period 1995/96. By the mid-1990's approximately four times the number of infants with birth weight less than 1,500 g were surviving compared with the early 1950s. The reduction in mortality rates occurred in all LBW groups during the first three decades. However, since 1981 infants who weighed less than 1,500 g at birth were the major contributors to the overall reduction in mortality. Between the years 1981/82 and 1995/96, survival increased significantly from 64% to 79% for infants with birth weight 1,000-1,499 g, and from 14% to 32% for those with birth weight less than 1,000 g. Since infants in the latter group were seldom offered mechanical ventilation or artificial surfactant, a large part of these increases in survival can be attributed to improvement in the general level of care. CONCLUSION: There have been dramatic improvements in the survival of LBW infants over this time period at Baragwanath Hospital. Although newer interventions such as mechanical ventilation and artificial surfactant have played a significant role, improvement in care at primary and secondary levels has been of major importance.

Is registrarship a different experience for women?

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