Can Western developmental screening tools be modified for use in a rural Malawian setting?

OBJECTIVE: To create a more culturally relevant developmental assessment tool for use in children in rural Africa. DESIGN: Through focus groups, piloting work and validation, a more culturally appropriate developmental tool, based on the style of the Denver II, was created. Age standardised norms were estimated using 1130 normal children aged 0-6 years from a rural setting in Malawi. The performance of each item in the tool was examined through goodness of fit on logistic regression, reliability and interpretability at a consensus meeting. The instrument was revised with removal of items performing poorly. RESULTS: An assessment tool with 138 items was created. Face, content and respondent validity was demonstrated. At the consensus meeting, 97% (33/34) of gross motor items were retained in comparison to 51% (18/35) of social items, and 86% (69/80) of items from the Denver II or Denver Developmental Screening Test (DDST) were retained in comparison to 69% (32/46) of the newly created items, many of these having poor reliability and goodness of fit. Gender had an effect on 23% (8/35) of the social items, which were removed. Items not attained by 6 years came entirely from the Denver II fine motor section (4/34). Overall, 110 of the 138 items (80%) were retained in the revised instrument with some items needing further modification. CONCLUSIONS: When creating developmental tools for a rural African setting, many items from Western tools can be adapted. The gross motor domain is more culturally adaptable, whereas social development is difficult to adapt and is culturally specific.

Antibiotic regimens for suspected early neonatal sepsis.

BACKGROUND: Early acquired infection may cause severe illness or death in the neonatal period. Prompt treatment with antibiotics has shown to reduce mortality. It is not clear which antibiotic regimen is suitable for treatment of presumed early neonatal sepsis. OBJECTIVES: To compare effectiveness and adverse effects of antibiotic regimens for treatment of presumed early neonatal sepsis. SEARCH STRATEGY: The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 2, 2003), MEDLINE (1966 to August 2003), EMBASE (1980 to September 2003) and ZETOC (1993 to August 2003) databases were searched for possible studies. Pharmaceutical companies were contacted for any unpublished data. SELECTION CRITERIA: Randomised and quasi-randomised controlled studies comparing antibiotic regimens for the treatment of early neonatal sepsis (both monotherapies and combination therapies). DATA COLLECTION AND ANALYSIS: Both reviewers screened abstracts and full reports against the inclusion criteria, appraised the quality of and extracted data from papers. For dichotomous outcomes, treatment effect was expressed as relative risk with 95% confidence interval. Meta-analysis was performed using a fixed effect model. MAIN RESULTS: Two small studies had compared monotherapy with combination therapy. There was no significant difference in mortality, treatment failure or bacteriological resistance. REVIEWERS' CONCLUSIONS: There is no evidence from randomised trials to suggest that any antibiotic regimen may be better than any other in the treatment of presumed early neonatal sepsis. More studies are needed to resolve this issue.

Clinical presentation and outcome of Pneumocystis carinii pneumonia in Malawian children.

BACKGROUND: Necropsy studies from Africa have shown that Pneumocystis carinii pneumonia (PCP) is common in infants with HIV infection. We aimed to describe the rate, clinical presentation, and outcome of PCP in young Malawian children with acute severe pneumonia. METHODS: Children aged between 2 months and 5 years who were in hospital with a diagnosis of severe pneumonia were admitted to a study ward for clinical monitoring. We carried out blood culture, immunofluorescence on nasopharyngeal aspirate samples to test for PCP, polymerase chain reaction to detect HIV, and chest radiography. FINDINGS: 16 cases of PCP were identified among 150 children with radiologically confirmed severe pneumonia. All were HIV-positive and younger than 6 months. 21 children had bacterial pneumonia (including one who was also PCP positive) and 114 were not confirmed. The most common bacterial pathogens among children without PCP were Streptococcus pneumoniae (eight) and non-typhoidal salmonellae (seven). On admission, children with confirmed PCP had a lower mean age, body temperature, and oxygen saturation than children with bacterial pneumonia and were less likely to have a focal abnormality on auscultation. Oxygen requirements were much greater in children with PCP than those with bacterial pneumonias (96 of 105 hospital days vs 15 of 94, p<0.0001). Ten of 16 children with PCP and six of 21 with bacterial pneumonia died (relative risk 2.19 [95% CI 1.0-4.7]). The overall case-fatality rate of severe pneumonia was 22%. In addition to a strong association with PCP, a fatal outcome was significantly and independently associated with HIV infection (2.98 [1.1-7.9]) and with age under 6 months (2.76 [1.0-5.2]). INTERPRETATION: PCP is common and contributes to the high mortality from pneumonia in Malawian infants. Clinical features are helpful in diagnosis. The study highlights the impact of HIV infection and difficult issues of management in countries with few resources.

Pneumocystis carinii pneumonia in Malawian children.

Sixty children aged between 1 and 23 months admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi for diagnosis of acute lower respiratory tract infections (ALRI) were investigated for laboratory diagnosis of Pneumocystis carinii pneumonia (PCP) by indirect immunofluorescence assay on nasopharyngeal secretions. P. carinii was found in five of the 60 children. Three PCP cases had AIDS. The clinical presentation of children with PCP was of little diagnostic value and all the children were infants. Arterial oxygen saturation was significantly lower in PCP cases. Of the five PCP cases, four died, indicating that the marked hypoxaemia was associated with poor prognosis. These results indicate that an immunofluorescence assay on nasopharyngeal secretions could be used for first-line diagnosis of PCP in Africa.

PIP: Indirect immunofluorescence assay of nasopharyngeal secretions from 60 children 1-23 months of age admitted to Queen Elizabeth Central Hospital in Blantyre, Malawi, with acute lower respiratory tract infections confirmed the presence of Pneumocystis carinii pneumonia (PCP) in 5 children. In Africa, diagnosis of PCP is generally based on clinical features, suspected immunosuppression, and chest radiography--all of which are limited in their capability to differentiate PCP from other pneumonias. 3 of the 5 infants diagnosed with PCP had AIDS. 14 children, including 8 of the 19 children with AIDS, died during hospitalization. 4 of the 5 children with PCP died, despite high-dose cotrimoxazole and oxygen therapy. In African children, PCP is often the first HIV-associated infection. More widespread use of the indirect immunofluorescence assay method is recommended for the rapid diagnosis of PCP cases in African children.

Cryptococcal meningitis in African children.

Three cases of cryptococcal meningitis in Malawian children aged 6 weeks, 3 years and 9 years are described. Only 23 cases of cryptococcal meningitis in children have been described previously, but in children from Europe and the USA. These are therefore the first cases of cryptococcosis to be described in African children.

PIP: The majority of cryptococcal meningitis cases in sub-Saharan Africa occur in adults infected with HIV. Reported in this paper are the first 3 cases of cryptococcal meningitis to involve African children. All 23 such cases reported to date in the literature have involved children from the US and Europe. The 3 African children--ages 6 weeks, 3 years, and 9 years--were from Malawi. Definitive evidence of HIV infection existed in the 9-year-old child, and the mother of the 6-week-old infant was HIV-seropositive. The mother of the 3-year-old child refused authorization of HIV serodiagnosis. None of the children had clinical signs of AIDS. The episode of cryptococcal meningitis was most likely the first AIDS-defining illness for these children. The 9-year-old child died 6 days after hospital admission.

Intention to deliver and delivery outcome

The labour outcome of the mothers who delivered at the Health Centre was not very different from that of the mothers who delivered at home. Whilst it was very encouraging to note that the majority of the mothers desired to deliver at the Health Centre; the lack of actually delivering at the Health Centre was very much in evidence