The outcome of non-typhoidal salmonella meningitis in Malawian children, 1997-2006.

INTRODUCTION: The clinical course and outcome of non-typhoidal salmonella (NTS) meningitis in Malawian children over a 10-year period (1997-2006) is described. METHODS: Demographic, clinical and laboratory data were collected for all children over 2 months of age admitted with salmonella meningitis to Queen Elizabeth Central Hospital from 1997 to 2006. In the 1st year, salmonellae were susceptible to chloramphenicol, and children received 2 weeks of chloramphenicol treatment. When NTS resistance to chloramphenicol started to appear in 1998, treatment was changed to ceftriaxone. From 2002, the duration of antibiotic therapy was extended to 4-weeks which included 2 weeks of intravenous ceftriaxone and a further 2 weeks of oral ciprofloxacin. RESULTS: The in-hospital case fatality rate (CFR) was 52.3% (48.2% until 2002 and 53.9% after prolonged antibiotic therapy was introduced). Of the survivors, one in 12 (8.3%) became completely well (sequelae-free) in the period 1997-2001 while 18 of 31 survivors (58.1%) made a complete recovery during 2002-2006 (p<0.01). After the 4-week course of antimicrobial therapy was introduced, the number of relapses or recurrences fell from nine in 15 (60%) survivors treated with chloramphenicol or ceftriaxone to three in 35 (8.7%) survivors who received 4 weeks of antibiotics (p<0.0001). CONCLUSION: In Malawi, salmonella meningitis has a CFR of approximately 50%, which has remained constant over many years. Residual morbidity, however, has decreased over 10 years, despite rising numbers of multi-drug-resistant cases of NTS. This improvement might be owing to better treatment and management and/or reduced pathogenicity of the multi-drug-resistant bacteria.

School hearing screening programme in the UK: practice and performance.

BACKGROUND: Paediatric audiology services and screening programmes are currently under review. AIMS AND METHODS: To investigate current practice and performance of the school hearing screening programme (SHSP) by means of a questionnaire. RESULTS: SHSP was found to detect previously unrecognised hearing loss at low cost. Wide variation in practice was shown, and the majority of services had no computerised system for data collection. CONCLUSION: There is a need for nationally agreed protocols and quality assurance procedures.

Normal values for distortion product otoacoustic emissions in children: a study using primary levels previously demonstrated to be optimum for identification of hearing loss.

No published data exist for normal values of distortion product otoacoustic emissions (DPOAE) in children at primary levels f1 = 65 dB and f2 = 55 dB SPL. These primary levels have been previously demonstrated to be optimal for identification of hearing impaired ears in adults. A total of 102 normal children underwent audiological assessment, including exclusion of middle ear disease, pure tone audiometry and DPOAE DP-grams (primaries L1/L2 = 65/55 dB SPL, f1:f2 = 1.22). There was a statistically significant decrease in DPOAE amplitude with increasing age. DPOAE amplitude was also dependent on the frequency of f2. However, there was wide inter- and intra-individual variation in DPOAE amplitude at different frequencies of f2. There was also a large overlap between the range of values of DPOAE amplitude between the adjacent age groups. Detailed assessment of DPOAE in children is feasible in the clinical setting. These normal values should prove invaluable in future studies; however, the large range of normal values means that cross-sectional studies may not be able to detect small variations in cochlear function.

Infantile overnutrition in the first year of life: a field study in Dudley, Worcestershire.

A survey of feeding patterns and nutrient intake in relation to the growth of 300 normal infants up to 1 year of age in Dudley, Worcestershire, highlights a problem of overnutrition in the group; 50 (16.7%) were found to be suffering from infantile obesity and a further 83 (27.7%) were overweight.During the first three months of life the daily energy intakes of 136 cal/kg body weight for boys and 149 for girls were markedly greater than the level of 120/kg recommended by the Department of Health and Social Security. This coincided with the early addition of solid foods to a full milk intake. 119 babies (39.7%) were offered solids before they were 4 weeks old and 280 (93.3%) before 13 weeks of age. Some babies had solids from the first week after birth. Protein intake was persistently high throughout the first year, and the mean intake of 32.7 g/day was much greater than the intake of 20 g for infants aged up to 1 year recommended by the Department of Health. Standards for fat and carbohydrate intake are not available but in comparison with the levels reported in breast-fed babies intake of fat and carbohydrate was high in the first three months and came closer to the desired level for the former and remained slightly high for the latter in the subsequent age quarters.The relation of childhood and subsequent adult obesity to infant feeding patterns is not yet clear, but there is a high correlation between obese parents and obese and overweight babies; had these babies not been overfed the condition might have been prevented.

Identification of permanent hearing loss in children: are the targets for outcome measures attainable?

A collaborative nine-centre study was designed to follow the routes to identification of all children up to the age of seven years newly diagnosed with permanent hearing impairment (> or = 50 dB HL) during the period 1993-1994. Ages of identification were compared with the standards set by the National Deaf Children's Society (NDCS), ascertaining whether these targets could be achieved with current service provision. Of the 126 children identified, 104 had congenital sensorineural hearing loss: 19% were identified by the age of six months and 39% by their first year. These results fall short of the NDCS targets of 40% and 80%, respectively, and point to the need for modifications of current practice, such as the introduction of universal neonatal screening.

Causes and outcome of bacterial meningitis in Malawian children.

598 children with bacterial meningitis were admitted to the paediatric wards of the Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi from July 1997 - March 2001. Patients were followed up at 1 and 6 months after hospital discharge when physical, neurological, developmental and hearing assessments were made. The most common causes of pyogenic meningitis were Streptococcus pneumoniae (40%), Haemophilus influenzae type b (28%), Neisseria meningitidis (11%), Salmonella species (5%). There was no growth on culture in 13% of cases. The overall mortality was 31% and 38% were left with significant sequelae. Indicators for a poor prognosis were younger age, lower coma score on admission, bacterial cause, nutritional status and HIV positivity.

The effect of HIV infection on paediatric bacterial meningitis in Blantyre, Malawi.

AIM: To compare presentation, progress, and outcome of acute bacterial meningitis in HIV seropositive and seronegative children. METHODS: A double blind randomised placebo controlled study of the use of dexamethasone as adjuvant therapy in acute bacterial meningitis, in children aged 2 months to 13 years, was carried out from July 1997 to March 2001. A total of 598 children were enrolled, of whom 459 were tested for HIV serostatus. RESULTS: Of the 459 children, 34% were HIV seropositive. Their presentation was similar to HIV seronegative children but more were shocked on arrival at hospital (33/157 v 12/302), and more had a focus of infection (85/157 v 57/302). HIV positive children had a higher incidence of Streptococcus pneumoniae infections (52% v 32%). Sixty four cases relapsed; 67% were in HIV positive patients. The mortality in HIV positive children was 65% compared with 36% in HIV negative children. The number of survivors in each group was similar. Hearing loss was more common in HIV negative than HIV positive children (66.3% v 47.2%). Steroid therapy had no influence on meningitis in HIV positive children, but the mortality in HIV negative children was 61% in children given steroids, and 39% in those who did not receive steroids. CONCLUSION: HIV seropositive children who develop bacterial meningitis have a high mortality and are prone to recurrent disease. There is an urgent need to prevent both primary and recurrent infections.

Dexamethasone treatment in childhood bacterial meningitis in Malawi: a randomised controlled trial.

BACKGROUND: Steroids are used as adjuvant treatment in childhood pyogenic meningitis to attenuate host inflammatory responses to bacterial invasion. We aimed to assess the effectiveness of dexamethasone in management of acute bacterial meningitis in a developing country. METHODS: In a double-blind, placebo controlled trial, we included 598 children with pyogenic meningitis who had been admitted to the children's wards of the Queen Elizabeth Central Hospital, Blantyre, Malawi. We did physical, neurological, developmental, and hearing assessments at 1 and 6 months after discharge. The primary outcome was overall death. Secondary outcomes included sequelae, in-hospital deaths, and death after discharge. Analysis was done by intention to treat. FINDINGS: Of the 598 included children, 307 (51%) were assigned to dexamethasone and 295 (49%) to placebo. 338 (40%) of 598 patients had Streptococcus pneumoniae, 170 (28%) Haemophilus influenzae type b, 66 (11%) Neisseria meningitidis, and 29 (5%) Salmonella spp. 78 (13%) patients had no growth on culture. The number of overall deaths was the same in the two treatment groups (relative risk 1.00 [95% CI 0.8-1.25], p=0.93). At final outcome, sequelae were identified in 84 (28%) of children on steroids and in 81 (28%) on placebo (relative risk 0.99 [95% CI 0.78-1.27], p=0.97). The number of children dying in hospital did not differ between groups. INTERPRETATION: Steroids are not an effective adjuvant treatment in children with acute bacterial meningitis in developing countries.