Weight Velocity in Addition to Latest Weight Does Not Improve the Identification of Wasting or the Prediction of Stunting and Mortality: A Longitudinal Analysis Using Data from Malawi, South Africa, and Pakistan.

BACKGROUND: In low/middle-income countries, most nutritional assessments use the latest weights, without reference to growth trajectory. OBJECTIVES: This study explores whether velocity, in addition to the latest weight, improves the prediction of wasting, stunting, or mortality in the first 2 years of life. METHODS: We analyzed a combined data set with weight and height data collected monthly in the first year of 3447 children from Pakistan, Malawi, and South Africa, with height and survival recorded till 24 m. The main exposures were weight-for-age z-score (WAZ) at the end of each 2-m period and weight velocity-for-age z-score (WVZ2) across that period. The outcomes were wasting, stunting, or all-cause mortality in the next 1-2 mo. As a sensitivity analysis, we also used WVZ over 6 mo (WVZ6), with matching WAZ. Cox proportional hazard models with repeated growth measures were used to study the association between exposures and mortality. Mixed Poisson models were used for stunting and wasting. RESULTS: Children who were already stunted or wasted were most likely to remain so. Higher WVZ2 was associated with a lower risk of subsequent stunting (risk ratio [RR]: 0.95; 95% confidence interval [CI]: 0.93, 0.96), but added minimal prediction (difference in AUC = 0.004) compared with a model including only WAZ. Similarly, lower WVZ2 was associated with wasting (RR: 0.74; 95% CI 0.72, 0.76) but the prediction was only marginally greater than for WAZ (difference in AUC = 0.015). Compared with WAZ, WVZ6 was less predictive for both wasting and stunting. Low WVZ6 (but not WVZ2) was associated with increased mortality (hazard ratios: 0.75, 95% CI: 0.67, 0.85), but added only marginal prediction to a model including WAZ alone (difference in C = 0.015). CONCLUSIONS: The key anthropometric determinant of impending wasting, stunting, and mortality appears to be how far below the normal range the child's weight is, rather than how they reached that position.

How to use autoantibodies in suspected paediatric rheumatic disease.

Autoantibodies can be an important indicator of paediatric rheumatic disease and useful in establishing a diagnosis. However, autoantibodies may be requested in cases where the patient does not have clinical features strongly suggestive of a rheumatic disease. This can lead to further unnecessary investigations, specialist referral and undue anxiety for the family. The aim of this article is to provide guidance for when it is appropriate to request autoantibodies, which ones to perform and how to interpret the results.

Wasting and Stunting in Infants and Young Children as Risk Factors for Subsequent Stunting or Mortality: Longitudinal Analysis of Data from Malawi, South Africa, and Pakistan.

BACKGROUND: Few studies have had sufficient longitudinal data to track how different malnourished states relate to mortality at different ages and interrelate over time. OBJECTIVES: This study aims to describe the RRs and proportions of mortality associated with wasting and stunting and the pathways into and out of these nutritional states. METHODS: Longitudinal growth data sets collected for children ages 0-24 months from Malawi, South Africa, and Pakistan were combined (n = 5088). Children were classified as deceased, wasted (weight for height < -2 SD; 1-4%), stunted (length < -2SD; 20-47%), or wasted and stunted (WaSt; 2-5%) at ages 3, 6, 9, 12, 18, and 24 months. Mixed-effects Cox models were used to study the association between nutritional status and mortality. RESULTS: By age 3 months, 20% of children were already stunted, rising to 49% by 24 months, while wasting (4.2% and 2.2% at 3 months, respectively) and WaSt (0.9% and 3.7% at 24 months, respectively) were less common. The HR for mortality in WaSt was 9.5 (95% CI, 5.9-15), but 60% of WaSt-associated mortality occurred at 3-6 months. Wasting or WaSt was associated with 10-23% of deaths beyond 6 months, but in the second year over half of deaths occurred in stunted, nonwasted children. Stunting persisted in 82% of children and wasting persisted in 44%. Wasted children were more likely than nonwasted, nonstunted children to become stunted (RR, 1.93; 95% CI, 1.7-2.2), but 94% of children who progressed to stunting had not been wasted in the prior period. CONCLUSIONS: WaSt greatly increased the risk of death, particularly in very young infants, but more deaths overall were associated with stunting. Most stunting appeared to be either intrauterine in origin or arose in children without prior wasting. Either stunting and wasting represent alternative responses to restricted nutrition, or stunting also has other, nonnutritional causes.

Communication with children and adolescents about the diagnosis of a life-threatening condition in their parent.

Many adults diagnosed with a life-threatening condition have children living at home; they and their partners face the dual challenge of coping with the diagnosis while trying to maintain a parenting role. Parents are often uncertain about how, when, and what to tell their children about the condition, and are fearful of the effect on their family. There is evidence that children are often aware that something is seriously wrong and want honest information. Health-care professionals have a key role in supporting and guiding parents and caregivers to communicate with their children about the diagnosis. However, the practical and emotional challenges of communicating with families are compounded by a scarcity of evidence-based guidelines. This Review considers children's awareness and understanding of their parents' condition, the effect of communication around parental life-threatening condition on their wellbeing, factors that influence communication, and the challenges to achieving effective communication. Children's and parents' preferences about communication are outlined. An expert workshop was convened to generate principles for health-care professionals, intended as practical guidance in the current absence of empirically derived guidelines.

Communication with children and adolescents about the diagnosis of their own life-threatening condition.

When a child is diagnosed with a life-threatening condition, one of the most challenging tasks facing health-care professionals is how to communicate this to the child, and to their parents or caregivers. Evidence-based guidelines are urgently needed for all health-care settings, from tertiary referral centres in high-income countries to resource limited environments in low-income and middle-income countries, where rates of child mortality are high. We place this Review in the context of children's developing understanding of illness and death. We review the effect of communication on children's emotional, behavioural, and social functioning, as well as treatment adherence, disease progression, and wider family relationships. We consider the factors that influence the process of communication and the preferences of children, families, and health-care professionals about how to convey the diagnosis. Critically, the barriers and challenges to effective communication are explored. Finally, we outline principles for communicating with children, parents, and caregivers, generated from a workshop of international experts.

Cryptogenic small-fiber neuropathies: Serum autoantibody binding to trisulfated heparan disaccharide and fibroblast growth factor receptor-3.

INTRODUCTION: Causes of small-fiber peripheral neuropathies (SFN) are often undefined. In this study we investigated associations of serum autoantibodies, immunoglobulin G (IgG) vs fibroblast growth factor receptor-3 (FGFR-3), and immunoglobulin M (IgM) vs trisulfated heparan disaccharide (TS-HDS) in cryptogenic SFN. METHODS: One hundred fifty-five patients with biopsy-proven SFN and no identified cause for their neuropathy were blindly tested for serum IgM vs TS-HDS and IgG vs FGFR-3. RESULTS: Forty-eight percent of SFN patients had serum antibodies, 37% with IgM vs TS-HDS and 15% with IgG vs FGFR-3. TS-HDS antibodies were more frequent in SFN patients than in controls (P = .0012). Both antibodies were more common in females, and with non-length-dependent nerve pathology. Nintey-two percent of patients with acute-onset SFN had serum IgM vs TS-HDS. DISCUSSION: Autoantibodies directed against TS-HDS and FGFR-3 suggest an immune disorder in otherwise idiopathic SFN. Serum IgM vs TS-HDS may be a marker for SFN with an acute onset.

Breastfeeding, HIV exposure, childhood obesity, and prehypertension: A South African cohort study.

BACKGROUND: Evidence on the association between breastfeeding and later childhood obesity and blood pressure (BP) is inconsistent, especially in HIV-prevalent areas where, until recently, HIV-infected women were discouraged from breastfeeding, but obesity is increasingly prevalent. METHODS AND FINDINGS: The Siyakhula cohort (2012-2014), a population-based prospective cohort study, collected data over 3 visits on HIV-negative children ages 7 to 11 years in rural South Africa. We used weight (body mass index [BMI]), fat, and BP as outcome variables and incorporated early life (including mother's age at delivery and HIV status) and current life factors (including maternal education and current BMI). Our primary exposure was breastfeeding duration. We dichotomized 3 outcome measures using pre-established thresholds for clinical interpretability: (1) overfat: ≥85th percentile of body fat; (2) overweight: >1 SD BMI z score; and (3) prehypertension: ≥90th percentile for systolic BP (SBP) or diastolic BP (DBP). We modelled each outcome using multivariable logistic regression, including stopping breastfeeding, then early life, and finally current life factors. Of 1,536 children (mean age = 9.3 years; 872 girls; 664 boys), 7% were overfat, 13.2% overweight, and 9.1% prehypertensive. Over half (60%) of the mothers reported continued breastfeeding for 12+ months. In multivariable analyses, continued breastfeeding between 6 and 11 months was associated with approximately halved odds of both being overfat (adjusted odds ratio [aOR] = 0.43, 95% confidence interval [CI] 0.21-0.91, P = 0.027) and overweight (aOR = 0.46, CI 0.26-0.82, P = 0.0083), but the association with prehypertension did not reach statistical significance (aOR = 0.72, CI 0.38-1.37, P = 0.32). Children with a mother who was currently obese were 5 times more likely (aOR = 5.02, CI 2.47-10.20, P < 0.001) to be overfat and over 4 times more likely to be overweight (aOR = 4.33, CI 2.65-7.09, P < 0.001) than children with normal weight mothers. Differences between HIV-exposed and unexposed children on any of the outcomes were minimal and not significant. The main study limitation was that duration of breastfeeding was based on maternal recall. CONCLUSIONS: To our knowledge, this is the first study examining and quantifying the association between breastfeeding and childhood obesity in an African setting with high HIV prevalence. We observed that breastfeeding was independently associated with reduced childhood obesity for both HIV-exposed and unexposed children, suggesting that promoting optimal nutrition throughout the life course, starting with continued breastfeeding, may be critical to tackling the growing obesity epidemic. In the era of widespread effective antiretroviral treatment for HIV-infected women for life, these data further support the recommendation of breastfeeding for all women.

Fever after meningococcal B immunisation: A case series.

AIM: To document the clinical features and management of infants presenting with fever after their first meningococcal B vaccination and develop guidance for clinicians. METHODS: A prospective case series over 12 months was conducted in a tertiary paediatric hospital. Infants ≤3 months of age with fever who had received their first set of immunisations within the preceding 72 h were included. RESULTS: A total of 92 infants met the inclusion criteria, accounting for 0.78% of the local vaccinated population. The most commonly described associated features were poor feeding, sleepiness and irritability; 66 patients (72%) were admitted to hospital. Median C-reactive protein (CRP) was 12 mg/L, and median white cell count (WCC) was 16 × 109 /L. Fifteen patients (16%) had a lumbar puncture and were commenced on antibiotics. There was one confirmed bacterial infection in an infant who had presented with fever starting 54 h after immunisation. All other microbiology samples were negative. There were no cases of missed serious bacterial infection (SBI) in those patients who were observed or discharged. CONCLUSIONS: The routine investigation of infants presenting with post-immunisation fever is not warranted if the infant appears otherwise well on examination. Where other common associated features are present or there is clinical concern, a period of observation is a prudent course of action. Paracetamol should be given peri-immunisation as per the national guidance. We suggest selective use of investigations, especially inflammatory markers, which are unlikely to discriminate between SBI and post-immunisation response. We advocate extra caution in infants presenting with fever more than 48 h after immunisation.

The immune response to sub-clinical mastitis is impaired in HIV-infected women.

BACKGROUND: Subclinical mastitis (SCM) is relatively common in lactating women and may be associated with HIV shedding in breast milk. The potential association between HIV infection and breast milk immunologic factors and immune response to SCM needs to be addressed. METHODS: In this cross-sectional study, SCM (Na/K ratio > 1) was tested in 165 mature breast milk samples collected from 40 HIV-infected women who didn't transmit HIV to their child by breastfeeding and 43 HIV-uninfected women enrolled in an interventional cohort in South-Africa (Vertical Transmission Study). The level of 33 immune markers related to Th1/Th2 related response, inflammation and bacterial exposure were compared in ART-naive HIV-infected versus HIV-uninfected women. The associations between HIV infection and SCM on the concentration of immune factors were tested separately by Wilcoxon rank-sum test and corrected for false discovery rate. To control for potential confounder effects and take into account the clustering of breast milk samples from a single woman, multivariate mixed linear models adjusted on child age at the time of sampling were performed for each immune factor. RESULTS: Subclinical mastitis was detected in 15 (37.5%) HIV-infected women and 10 (23.3%) HIV-uninfected women. In the absence of SCM, the breast milk levels of IP-10 and MIG were higher and IL1-RA lower in HIV-infected women than in HIV-uninfected women (respectively p < 0.001, p = 0.001, p = 0.045). In HIV-uninfected women, SCM was characterized by a robust immune response with higher concentrations of a broad panel of Th1 and inflammatory related immune markers than in samples without SCM. By contrast, in HIV-infected women a limited number of immune markers were increased and lower increases were observed in samples with SCM than without SCM. CONCLUSION: HIV infection in ART-naïve women was associated with elevated breast milk levels of IP-10 and MIG, which areTh1-related cytokines induced by IFN-γ. During SCM, a lower and narrower immune response was observed in HIV-infected than HIV-uninfected women, suggesting that HIV infection affects the capacity of the mammary gland to respond to SCM.

Incidence of nonamyloidogenic mutations in the transthyretin gene in patients with autonomic and small fiber neuropathy.

INTRODUCTION: Mutations of the transthyretin (TTR) gene have been associated with polyneuropathy; the protein product has a tendency to form amyloid deposits in the peripheral nervous system. METHODS: Patients with small fiber neuropathy (SFN) with or without autonomic symptoms were given skin biopsies to assess nerve fiber density. Any patient with autonomic symptoms was assessed for autonomic neuropathy (AN). If testing revealed no clear cause of neuropathy, the TTR gene was sequenced. RESULTS: Thirty-six percent of patients were found to harbor at least 1 mutation in the TTR gene sequence (variants of unknown significance [VUS]). Of 24 patients diagnosed with SFN, 8% of patients had a point mutation (c76G>A). Of those patients who were diagnosed with both SFN and AN, 68% of patients had a VUS within the TTR gene (c76G>A, c337-18G>C). CONCLUSIONS: The results suggest an association between presumed nonamyloidogenic mutations in the TTR gene and the development of AN and SFN. Muscle Nerve 57: 140-142, 2017.

Prevalence and risk factors for child mental disorders in a population-based cohort of HIV-exposed and unexposed African children aged 7-11 years.

Despite being home to a large population of vulnerable children there is a dearth of population-based evidence on childhood mental disorders in sub-Saharan Africa. Parent and child mental health are rarely measured concurrently, despite potential for confounding with other risk factors, including parental HIV. Using the parent-report Child Behaviour Checklist (CBCL) we assessed children's mental health in a population-based cohort of 1536 HIV-negative children (31% HIV-exposed, 18% HIV-affected, 51% HIV-unexposed) aged 7-11 years. CBCL was scored using CBCL Rating-to-Score software. A binary indicator was determined using the clinical threshold ≥ 65. We modelled mental disorders using logistic regression, including covariates associated with the mother, child, household, and parenting. Structural equation modelling techniques also derived continuous latent variables representing the underlying mental health and parent-relationship constructs. Prevalence of conduct disorders (11.8%) was high, regardless of HIV exposure, while HIV-affected children had increased odds of affective disorders. Maternal depression increased odds of externalising disorders; maternal anxiety was associated with affective and anxiety disorders. Mother-child relationship dysfunction increased odds of all disorders, including: affective [aOR = 5.1 (2.6-9.9)]; oppositional [aOR = 7.9 (4.0-15.5)]; conduct [aOR = 4.3 (2.6-7.2)] disorders. Food insecurity and male gender increased odds of somatic disorders; breastfeeding halved odds of conduct disorders. In the latent model, associations were substantially stronger for the mother-child relationship and externalising disorders (Oppositional 0.464 p < 0.001; Conduct 0.474 p = <0.001). Conduct disorders were high for all children regardless of HIV exposure. The mother-child relationship was strongly related to all child disorders, suggesting potential for concurrent interventions targeting child behaviours and the parent-child or mother-child relationship.

Fifteen-minute consultation: The child with an incidental finding of low IgA.

Low or absent immunoglobulin A (IgA) levels are frequently found in children in whom immunodeficiency is not suspected. IgA deficiency is the most common primary immunodeficiency disorder in the UK affecting approximately 1 in 600 people. Isolated IgA deficiency is often identified coincidentally when investigating a child for conditions such as coeliac disease. The aim of this article is to provide a structured approach to the history, investigation and management of an isolated IgA deficiency.

Subclinical mastitis occurs frequently in association with dramatic changes in inflammatory/anti-inflammatory breast milk components.

BACKGROUND: Subclinical mastitis (SCM) is a frequent, but poorly characterized entity that may influence immune development of breastfed infants. Mechanisms driving the emergence of SCM and changes in immunological content of human milk during SCM remain to be explored. In this study, the breast milk environment was to describe during SCM. METHODS: One hundred and ten samples of mature breast milk were collected from 44 healthy, HIV-negative mothers, included in a large infant feeding intervention cohort (ANRS 1271/Vertical Transmission Study). Immune markers related to inflammatory/anti-inflammatory balances and secreted in response to bacterial exposure were explored in SCM breast milk samples (Na/K ratio > 1) and compared to non-SCM controls. RESULTS: SCM was observed in 23% of women (95% confidence interval (CI): 21-24) and associated with higher levels of inflammatory markers (ß2 microgobulin, PS100A9, TNF-α, IL-6, IL-8, IL-17, and RANTES) and Th1-related cytokines (IL-2R, IL-12p40/70, IFN-α, IFN-γ, CXCL-9, andIP-10). High levels of factors secreted in response to bacteria and lipopolysaccharide (LPS) exposure were observed in SCM breast milk samples (MIP-1α, MIP-1ß, LPS binding protein, α-defensins, and antileukoproteinase 1). CONCLUSION: SCM is associated with important changes in breast milk microenvironment, with a proinflammatory/Th1-cytokine predominant profile. During SCM, cytokine imbalances in breast milk may have a notable influence on mucosal immune system of the infant early in life.

Health impact of catch-up growth in low-birth weight infants: systematic review, evidence appraisal, and meta-analysis.

This study aimed to systematically review and appraise evidence on the short-term (e.g. morbidity, mortality) and long-term (obesity and non-communicable diseases, NCDs) health consequences of catch-up growth (vs. no catch-up growth) in individuals with a history of low birth weight (LBW).We searched MEDLINE, EMBASE, Global Health, CINAHL plus, Cochrane Library, ProQuest Dissertations and Thesis and reference lists. Study quality was assessed using the risk of bias assessment tool from the Agency for Health Care Research and Quality, and the evidence base was assessed using the GRADE tool. Eight studies in seven cohorts (two from high-income countries, five from low-middle-income countries) met the inclusion criteria for short-term (mean age: 13.4 months) and/or longer-term (mean age: 11.1 years) health outcomes of catch-up growth, which had occurred by 24 or 59 months. Of five studies on short-term health outcomes, three found positive associations between weight catch-up growth and body mass and/or glucose metabolism; one suggested reduced risk of hospitalisation and mortality with catch-up growth. Three studies on longer-term health outcomes found catch-up growth were associated with higher body mass, BMI or cholesterol. GRADE assessment suggested that evidence quantity and quality were low. Catch-up growth following LBW may have benefits for the individual with LBW in the short term, and may have adverse population health impacts in the long-term, but the evidence is limited. Future cohort studies could address the question of the consequences of catch-up growth following LBW more convincingly, with a view to informing future prevention of obesity and NCDs. © 2016 John Wiley & Sons Ltd.

Exclusive Breastfeeding and Cognition, Executive Function, and Behavioural Disorders in Primary School-Aged Children in Rural South Africa: A Cohort Analysis.

BACKGROUND: Exclusive breastfeeding (EBF) is associated with early child health; its longer-term benefits for child development remain inconclusive. We examine the associations between EBF, HIV exposure, and other maternal/child factors and the cognitive and emotional-behavioural development of children aged 7-11 y. METHODS AND FINDINGS: The Vertical Transmission Study (VTS) supported EBF in HIV-positive and HIV-negative women; between 2012 and 2014, HIV-negative VTS children (332 HIV exposed, 574 HIV unexposed) were assessed in terms of cognition (Kaufman Assessment Battery for Children Second Edition [KABC-II]), executive function (Developmental Neuropsychological Assessment Second Edition [NEPSY-II]), and emotional-behavioural functioning (parent-reported Child Behaviour Checklist, [CBCL]). We developed population means by combining the VTS sample with 629 same-aged HIV-negative children from the local demographic platform. For each outcome, we split the VTS sample into scores above or at/below each population mean and modelled each outcome using logistic regression analyses, overall and stratified by child sex. There was no demonstrated effect of EBF on overall cognitive functioning. EBF was associated with fewer conduct disorders overall (adjusted odds ratio [aOR] 0.44 [95% CI 0.3-0.7], p ≤ 0.01), and there was weak evidence of better cognition in boys who had been exclusively breastfed for 2-5 mo versus ≤1 mo (Learning subscale aOR 2.07 [95% CI 1.0-4.3], p = 0.05). Other factors associated with better child cognition were higher maternal cognitive ability (aOR 1.43 [95% CI 1.1-1.9], p = 0.02, Sequential; aOR 1.74 [95% CI 1.3-2.4], p < 0.001, Planning subscales) and crèche attendance (aOR 1.96 [95% CI 1.1-3.5], p = 0.02, Sequential subscale). Factors positively associated with executive function were home stimulation (aOR 1.36 [95% CI 1.0-1.8], p = 0.04, Auditory Attention; aOR 1.35 [95% CI 1.0-1.8], p = 0.05, Response Set) and crèche (aOR 1.74 [95% CI 1.0-3.0], p = 0.05, Animal Sorting). Maternal mental health problems and parenting stress were associated with increased emotional-behavioural problems on the total CBCL (aOR 2.44 [95% CI 1.3-4.6], p = 0.01; aOR 7.04 [95% CI 4.2-11.9], p < 0.001, respectively). Maternal HIV status was not associated with any outcomes in the overall cohort. Limitations include the nonrandomised study design and lack of maternal mental health assessment at the child's birth. CONCLUSIONS: EBF was associated with fewer than average conduct disorders and weakly associated with improved cognitive development in boys. Efforts to improve stimulation at home, reduce maternal stress, and enable crèche attendance are likely to improve executive function and emotional-behavioural development of children.

Video observations of treatment administration to children on antiretroviral therapy in rural KwaZulu-Natal.

For children younger than five years, caregivers are responsible for the measurement and administration of antiretroviral medication doses to children. Failure to adhere to the regimen as prescribed may lead to high viral loads (VLs), immune suppression and ultimately drug resistance. In the content of this study, adherence refers to adequate dosing of the medication by a caregiver. Acquired drug resistance to antiretroviral therapy (ART) is prevalent amongst children in South Africa, and poor adherence to the dosing regimen by caregivers may be associated with this problem. In this qualitative study, we purposively recruited 33 caregiver-child dyads from the Hlabisa HIV Treatment and Care Programme database. Children were divided into three groups based on their VL at the time of recruitment. Children with a VL ≥ 400 cps/ml were grouped as unsuppressed (n = 11); children with a VL ≤ 400 cps/ml were grouped as suppressed (n = 12); and children with no VL data were grouped as newly initiated (n = 10). Caregiver-child dyads were visited at their households twice to document, by means of video recording, how treatment was administered to the child. Observational notes and video recordings were entered into ATLAS.ti v 7 and analysed thematically. Results were interpreted through the lens of Ecological Systems Theory and the information-motivation-behavioural skills model was used to understand and reflect on several of the factors influencing adherence within the child's immediate environment as identified in this study. Thematic video analysis indicated context- and medication-related factors influencing ART adherence. Although the majority of children in this sample took their medicine successfully, caregivers experienced several challenges with the preparation and administration of the medications. In the context of emerging drug resistance, efforts are needed to carefully monitor caregiver knowledge of treatment administration by healthcare workers during monthly clinic visits.

Shortcomings of adherence counselling provided to caregivers of children receiving antiretroviral therapy in rural South Africa.

In order to achieve optimal benefits of antiretroviral therapy (ART), caregivers of children receiving ART are required to attend routine clinic visits monthly and administer medication to the child as prescribed. Yet, the level of adherence to these behaviours varies considerably in many settings. As a way to achieve optimal adherence in rural KwaZulu-Natal, caregivers are required to attend routine counselling sessions at HIV treatment clinics that are centred on imparting information, motivation, and behavioural skills related to medication administration. According to the information-motivation-behavioural skills model, information related to adherence, motivation, and behavioural skills are necessary and fundamental determinants of adherence to ART. The purpose of the study was to observe and document the content of adherence counselling sessions that caregivers attending rural clinics in KwaZulu Natal receive. We observed 25 adherence counselling sessions, which lasted on average 8.1 minutes. Counselling typically consisted of counsellors recording patient attendance, reporting CD4 count and viral load results to caregivers, emphasising dose times, and asking caregivers to name their medications and dosage amounts. Patients were seldom asked to demonstrate how they measure the medication. They were also not probed for problems regarding treatment, even when an unsuppressed VL was reported to a caregiver. This paper calls attention to the sub-optimal level of counselling provided to patients on ART and the urgent need to standardise and improve the training, support, and debriefing provided to counsellors.

Impact of adherence to WHO infant feeding recommendations on later risk of obesity and non-communicable diseases: systematic review.

Adherence to WHO infant feeding recommendations has short-term benefits and may also help in the prevention of non-communicable diseases (NCDs). This study reviewed the evidence on whether adherence to all elements of the WHO infant feeding recommendations (comparison group those exclusively breastfed to 6 months, introduced to appropriate complementary feeding from 6 months, with continued breastfeeding to at least 24 months; exposure group characterised by non-adherence to any of the three recommendations) is associated with reduced risk of later obesity or cardiometabolic disease. The population of interest was children not classified as very low weight (weight-for-age z-score >-3.0). MEDLINE, EMBASE, Global Health, CINAHL plus, ProQuest Dissertations and Thesis were systematically searched from 2001 to July 2014, manual reference searching of a birth cohort register (http://www.birthcohorts.net/) as well as papers identified in the search and selected journals was carried out. The database search yielded 9050 records, 275 English-language full-text articles were screened, but no studies were eligible, failing to meet the following criteria: comparison (213); exposure (14); population (3); relevant outcome (5); outcome before 24 months (9); insufficient information provided (30); plus one study was qualitative. Eight studies met the inclusion criterion of exclusive breastfeeding to 6 months, but did not meet the other inclusion criteria. The present study has revealed an important gap in the evidence on NCD prevention, and suggestions for addressing this evidence gap are provided.

Barriers and facilitators to paediatric adherence to antiretroviral therapy in rural South Africa: a multi-stakeholder perspective.

Poor adherence to antiretroviral therapy (ART) contributes to the development of drug resistance. HIV-infected children, especially those 5 years and under, are dependent on a caregiver to adhere to ART. However, characteristics of the caregiver, child, regimen, clinic and social context affect clinic attendance and medication-taking, both of which constitute adherent behaviour. We conducted nine interviews and three focus groups to determine how doctors, nurses, counsellors, traditional healers and caregivers understood the barriers and facilitators to ART adherence among children residing in rural South Africa. The data were transcribed, translated into English from isiZulu where necessary, and coded using Atlas.ti version 7. Results were interpreted through the lens of Bronfenbrenner's Ecological Systems Theory. We found that at the micro-level, palatability of medication and large volumes of medication were problematic for young children. Characteristics of the caregiver including absent mothers, grandmothers as caregivers and denial of HIV amongst fathers were themes related to the micro-system. Language barriers and inconsistent attendance of caregivers to monthly clinic visits were factors affecting adherence in the meso-system. Adherence counselling and training were the most problematic features in the exo-system. In the macro-system, the effects of food insecurity and the controversy surrounding the use of traditional medicines were most salient. Increased supervision and regular training amongst lay adherence counsellors are needed, as well as regular monitoring of the persons attending the clinic on the child's behalf.