Errors in anthropometric measurements in neonates and infants.

The accuracy of methods used in Cape Town hospitals and clinics for the measurement of weight, length and age in neonates and infants became suspect during a survey of 12 local authority and 5 private sector clinics in 1994-1995 (Harrison et al. 1998). A descriptive prospective study to determine the accuracy of these methods in neonates at four maternity hospitals [2 public and 2 private] and infants at four child health clinics of the Cape Town City Council was carried out. The main outcome measures were an assessment of three currently used methods namely to measure crown-heel length with a measuring board, a mat and a tape measure; a comparison of weight differences when an infant is fully clothed, naked and in napkin only; and the differences in age estimated by calendar dates and by a specially designed electronic calculator. The results showed that the current methods which are used to measure infants in Cape Town vary widely from one institution to another. Many measurements are inaccurate and there is a real need for uniformity and accuracy. This can only be implemented by an effective education program so as to ensure that accurate measurements are used in monitoring the health of young children in Cape Town and elsewhere.

An assessment of the 'road-to-health' card based on perceptions of clinic staff and mothers.

OBJECTIVES: To describe the opinions of health personnel and parents at child health clinics in Cape Town; to determine the accuracy and completeness of data recorded on the present 'Road-to-Health' (RTH) card; and to ascertain the views of clinic staff and mothers regarding what information they would like to record. DESIGN: Descriptive prospective study. SETTING AND SUBJECTS: Qualitative interviews of 35 health personnel and 150 mothers/caregivers were conducted at 17 child health clinics. The clinic practices of 32 health personnel were monitored and details of 150 RTH cards were examined. MAIN OUTCOME MEASURES: Responses of health personnel at public and private child health clinics and of mothers were analysed. Data recorded on the card were extracted under the headings: neonatal data, immunisation schedules, measurements, and weight-for-age chart. RESULTS: Most nurses supported the concept of an RTH card but a large majority recommended that it be replaced with a notebook retained by the mother. A significant proportion of health personnel did not know how to use the weight-for-age chart. Most mothers attending clinics carried the card, but this number dropped for hospital visits and consultations with private doctors. Mothers' understanding of the card was limited. For mothers the weight-for-age chart, immunisation schedule and milestone section are obscure. CONCLUSION: Health personnel and mothers would like to replace the RTH card with a notebook in the parents' home language. It should contain more information on health matters, adequate space to record weight and infectious diseases, an illustrated milestone chart and an improved schedule for immunisations. Mothers perceived the RTH card as belonging to the clinic and wanted a 'baby's own' document.

Plasma free iron: a possible cause of oedema in kwashiorkor.

BACKGROUND: Oedema is a sine qua non for the diagnosis of kwashiorkor yet the mechanisms leading to oedema remain ill defined. AIMS: To relate the plasma concentration of radical promoting 'free' iron to the degree of oedema in patients with kwashiorkor. SETTING: University teaching hospital. PATIENTS: Fifteen children with kwashiorkor, nine of whom had severe and six of whom had a moderate degree of oedema. METHODS: Plasma 'free' iron was measured as bleomycin detectable iron (BDI) and related to severity of oedema and plasma albumin concentration. RESULTS: BDI was significantly higher in the patients with severe oedema (20.5 v 6.75 mumol/l) whereas the albumin concentrations were similar (16 v 17 g/l). BDI was no longer present in any patients 30 days after admission. CONCLUSIONS: 'Free' circulating iron may contribute to the oedema of kwashiorkor, and its sequestration could hasten recovery and decrease morbidity and mortality.

Bone marrow and chelatable iron in patients with protein energy malnutrition.

OBJECTIVES: To examine the iron status of malnourished children by comparing bone marrow iron deposits in children with protein energy malnutrition with those in well-nourished controls, and measuring chelatable urinary iron excretion in children with kwashiorkor. DESIGN: Bone marrow iron was assessed histologically in postmortem specimens from children with kwashiorkor or marasmus, and from controls. Twenty-four-hour urinary iron was measured in children with severe kwashiorkor, half of whom received 10 mg/kg of intramuscular desferrioxamine (DFO) on admission. SETTING: Red Cross War Memorial Children's Hospital, Cape Town. SUBJECTS: Thirteen children with kwashiorkor, 6 with marasmus and 16 well-nourished children underwent bone marrow examination. Urinary iron excretion was assayed in 17 children with kwashiorkor. RESULTS: Stainable iron was present in the bone marrow of half the children with kwashiorkor but in only 1 child in each of the other groups. The median iron excretion was 945.5 micrograms/24 hours in the DFO group compared with 28.5 micrograms/24 hours in the non-DFO group. CONCLUSIONS: There is an apparent excess of iron which may predispose to bacterial infections and free radical-mediated injury in children with kwashiorkor.

Red blood cell antioxidant enzyme concentrations in kwashiorkor and marasmus.

Kwashiorkor may occur when an imbalance between pro- and antioxidants in malnourished children results in an excess of free radicals. The concentrations of the antioxidant enzymes catalase (CAT), superoxide dismutase (SOD), reduced glutathione (GSH) and glutathione peroxidase (GPX) were measured in erythrocytes of 22 children with kwashiorkor on admission to hospital and repeated on days 5, 10 and 30 of recovery. The concentrations were compared with those in 22 children with marasmus and in 20 children who were normally nourished but had infective illness necessitating their hospitalization. CAT and SOD were similar in all groups and did not change during recovery. GSH and GPX were significantly lower in kwashiorkor than in the other groups. Concentrations of thiobarbituric acid-reactive substances (TBARS), a marker of lipid peroxidation, were significantly elevated in children with kwashiorkor. During clinical recovery, GSH but not GPX concentrations rose despite an increase in plasma selenium levels and decreased concentrations of TBARS. These findings suggest that the antioxidant status of children with kwashiorkor differs from that of well nourished and marasmic children. Whether these differences are the cause of the consequence of the clinical picture is unresolved.

Comparison of enteral and intramuscular vitamin A supplementation in preterm infants.

Vitamin A deficiency associated with preterm delivery is not readily reversible using the recommended supplement of 1500 IU per day. It has been reported that 2000 IU of intramuscular vitamin A administered on alternate days for 28 days will correct the deficiency. The objective of this study was to compare this regime with the practice in our nursery of giving 5000 IU of vitamin A per day with the early introduction of feeds. The vitamin A status of ten preterm infants (mean gestation 30.5 weeks) who received intramuscular vitamin supplementation was compared with that of nine infants (mean gestation 30.7 weeks) given enteral vitamin A. Vitamin A status was evaluated on the 32nd day of life using plasma retinol and retinol-binding protein (RBP) concentrations and a modified relative dose response (RDR) test. Plasma retinol and RBP concentrations were similar in the two groups shortly after birth revealing vitamin A deficiency. By the 32nd day of life, plasma retinol and RBP concentrations had risen significantly in both groups and in 70% the modified RDR was normal. Differences between the groups were not observed irrespective of the method of vitamin A administration. None of the infants developed clinical or biochemical vitamin A toxicity. In most preterm infants who tolerate feeds, vitamin A deficiency can be corrected safely by supplementing the feeds with 5000 IU of vitamin A per day.

Plasma zinc, copper, selenium, ferritin and whole blood manganese concentrations in children with kwashiorkor in the acute stage and during refeeding.

Plasma zinc, copper, selenium, ferritin and whole blood manganese concentrations were measured in 22 children with kwashiorkor on admission to hospital and on days 5, 10 and 30 of refeeding. Twenty similarly aged, healthy, well nourished children served as controls. The mean (SEM) zinc, copper and selenium concentrations of 7.5 (0.93), 10.8 (0.64) and 0.29 (0.02) mumol/l, respectively, in the children with kwashiorkor on admission were all significantly lower than the values of 13.7 (0.66), 25.6 (1.72) and 0.72 (0.04) mumol/l in the controls. In contrast, the erythrocyte manganese level of 1.67 (0.09) micrograms/gHb and the median ferritin concentration of 293 micrograms/dl were significantly higher than in the controls. After 30 days there was full clinical recovery with significant weight gain and a return of the plasma albumin, caeruloplasmin, copper and ferritin to normal. However, manganese remained elevated and zinc and selenium concentrations remained significantly low. Our results suggest that nutritional rehabilitation of children with kwashiorkor is incomplete by 30 days and cannot be judged purely by a return of the plasma proteins to normal. Addition of selected trace elements to the diet may hasten full recovery.

Iron fortification of infant milk formula: the effect on iron status and immune function.

We conducted a randomized double-blind trial of a cow's milk infant formula with increased iron fortification in order to confirm its safety and to measure its effects on iron status and immune function. A group of full-term, well nourished and healthy infants was followed from the age of 3 months to 1 year. A control group of 74 infants was given a commercially available infant formula containing 8.3 mg Fe/100g. The test group of 75 infants received a similar formula with 40 mg Fe/100 g. The formula with the extra iron proved to be safe and, when compared with the control group, the children in the test group had significantly improved iron status as reflected by the proportion of children classed as normal (25 of 61 cf. 44 of 65; p less than 0.003), and by the mean values of the haemoglobin concentration (11.5 cf. 11.9 g/dl; p = 0.04), red cell distribution width (15.5% cf. 14.4%; p = 0.0005), red cell zinc protoporphyrin (3.4 cf. 4.0 micrograms/g Hb; p = 0.04) and ferritin (29 cf. 17.3 micrograms/l; p = 0.004). The extra iron fortification depressed zinc concentration in plasma (90.6 cf. 83.5 micrograms/l; p = 0.05). There was no significant difference between the two groups for laboratory measures of immune function or for incidence of infection. No adverse effects such as infection could be attributed to the increased iron. We conclude that iron fortification of cow's milk infant formula may be safely increased to 40 mg/100 g (i.e. by a factor of 4.8 over the common concentration of 8.3 mg/100 g), but that this has less than the expected effect on iron status. Further studies are required to define (a) the long-term role of facilitators of iron absorption such as ascorbic acid, (b) the interaction of iron with absorption of divalent trace elements such as zinc, and (c) the effect of iron status on immune function and susceptibility to infection.

Medical manpower--South African situation models for planning and recommendations.

Imbalances in medical manpower in South Africa are outlined. Theoretical publications on health manpower development are reviewed, with particular reference to factors and problems to be considered when estimating health manpower needs. Four models (health demand, health needs, service target and manpower/population ratio) of health manpower planning are described and their applicability to the South African situation is discussed. Recommendations for health manpower development in South Africa, especially for primary health care, are made.

Prevention of iron deficiency in preterm neonates during infancy.

The preterm infant inevitably develops iron deficiency unless supplementary iron is given. Oral iron supplementation is preferred in ideal social circumstances but, where compliance with such therapy is uncertain, intramuscular iron dextran may be a more effective treatment. A study was conducted to compare the effectiveness of two methods of preventing iron deficiency of prematurity. One group of healthy premature infants was given oral iron 2 mg/kg/d until the age of 6 months. The second similar group was given 100 mg as intramuscular iron dextran (Imferon; Fisons) between the ages of 6 and 8 weeks. Both kinds of supplementary iron appeared to have benefited the majority of infants in this trial.

Genetic and environmental influences on cord blood serum IgE and on atopic sensitisation in infancy.

It has recently been reported that cord blood serum IgE (CBsIgE) concentrations in a black Third-World cohort were significantly higher than those in a similar cohort of white and coloured newborns, and were not influenced by an atopic family history (aFH). This study reports on the 1-year follow-up of these newborns carried out to determine whether statistical differences in median CBsIgE values at birth could be found between infants in each ethnic group who subsequently developed clinical atopy in the first year of life and those who remained healthy. The infants were seen at 3, 7 and 12 months of age. At each visit a detailed history was taken from the mothers, the infants were examined clinically for the presence of atopic disease and blood was taken for immunological assay (total serum IgE by paper-disc radio-immunosorbent testing, and radio-allergosorbent testing for egg-white, cow's milk and Dermatophygoides pteronyssinus). A combination of clinical and immunological variables was assessed in order to categorise the infants into 'atopic' or 'not atopic' groups at the end of the 1-year follow-up period. The black infants who completed the study had the lowest incidence of aFH (16%), but 64% of them developed atopic disease during infancy. The median CBsIgE values for the black infants who became atopic were lower than, but not statistically different from, those for the group who remained non-atopic (P = 0.57). The white and coloured infants who completed the study had 81.6% and 30.4% incidences of aFH respectively, with 47.4% and 58.7% respectively developing atopic disease during infancy.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of ethnicity, an atopic family history, and maternal ascariasis on cord blood serum IgE concentrations.

Raised concentrations of cord blood serum (CBs) IgE have previously been demonstrated to reflect a hereditary predisposition for atopy in First World, predominantly white populations. A cross-sectional study of 53 black, 52 white, and 58 mixed race newborn infants and maternal pairs was performed in a multiethnic, mixed First and Third World society. The CBs IgE concentrations were measured with a modification of the standard IgE PRIST, which could reliably determine IgE concentrations to an accuracy of 0.01 kU/L. The black group had the highest geometric mean and median CBs IgE concentrations (0.21; 0.16 kU/L), followed by the white group (0.12; 0.12 kU/L) and the mixed group (0.10; 0.08 kU/L). If those newborn infants with an atopic family history and maternal ascariasis were excluded, the remainder had geometric mean and median CBs IgE concentrations of 0.20; 0.16 kU/L in the black subgroup, followed by values of 0.06; 0.05 kU/L in the mixed subgroup, and 0.05; 0.07 kU/L in the white subgroup. Statistically significant ethnic differences in the median CBs IgE concentrations of these subgroups were demonstrated between the black-white (p less than 0.05) and the black-mixed (p less than 0.005) ethnic groups. A positive family history of atopy influenced the CBs IgE concentrations in the white and mixed groups but not in the black group. Of those newborn infants with a CBs IgE concentration greater than 0.5 kU/L, a family history of atopy was found in 100% of the white newborn infants, in 58.3% of the mixed newborn infants, and only in 14.3% of the black newborn infants. Many of the black newborn infants without a family history of atopy had extremely high CBs IgE concentrations. The influence of maternal ascariasis was equivocal in the mixed group but of no significance in the black group. The high CBs IgE concentrations in the black newborn infants, independent of an atopic family history and maternal ascariasis, suggest that this atopic marker may therefore be of limited use in identifying the "high allergic-risk" newborn infant in black Third World populations who appear to represent a pool of genetic high IgE-responder phenotypes.

Serum vitamin C, vitamin A and carotene values in infants in SWA/Namibia.

Serum vitamin C, vitamin A and carotene concentrations were measured in 425, 256 and 256 infants aged between 3 weeks and 12 months. Vitamin C concentrations were in general satisfactory, whereas vitamin A and especially carotene concentrations were unacceptably low in a large number of infants. concentrations were not correlated with age and sex nor with breast-feeding, but low and very low concentrations were more common after 6 months. Although clinical manifestations of the vitamin deficiencies were not present, the evidence points to an increased health risk for children.

Reference concentrations of serum selenium and manganese in healthy nulliparas.

Reference serum selenium and manganese concentrations were established for healthy nulliparas aged 18-23 years resident in Cape Town. Measurements were determined for selenium in 100 female students who had been taking low-dosage triphasic contraceptive medication for a minimum of 3 months and in 100 female students who were not on contraceptive therapy. Manganese concentrations were determined for 25 female students from each group. The mean serum selenium concentrations were 0.988 +/- 0.189 micrograms/l (78 +/- 15 micrograms/dl) and 0.925 +/- 0.177 mumol/l (73 +/- 14 micrograms/l) respectively for females taking and not taking oral contraceptives. The corresponding concentrations for manganese were 21.84 +/- 9.82 nmol/l (1.20 +/- 0.54 micrograms/l) and 21.66 +/- 7.64 nmol/l (1.19 +/- 0.42 micrograms/l) respectively. The differences in selenium were statistically significant (P = 0.0231) but not for manganese (P = 0.910).

Reference values for serum copper, ceruloplasmin and zinc and haematological indices for healthy nulliparous females.

Reference serum copper, ceruloplasmin and zinc values were established for 100 healthy white nulliparous students aged 18-23 years resident in Cape Town who had been taking low-dosage triphasic contraceptives for a minimum period of 3 months, and in 100 female students not taking contraceptives. The mean serum copper values were 26.5 +/- 4.2 mumol/l and 16.9 +/- 2.7 mumol/l for those taking and not taking oral contraceptives respectively; corresponding values for ceruloplasmin were 181 +/- 43.9 IU/ml and 110 +/- 22.7 IU/ml respectively. Both differences were statistically significant. Serum zinc values for those on contraceptives were 14.1 +/- 2.1 mumol/l and for the others 14.7 +/- 2.0 mumol/l. There were no differences in the haematological parameters except for a significantly higher mean corpuscular volume in females taking oral contraceptives. Of possible clinical significance in this student population are prevalence rates of 2.2% for anaemia (haemoglobin value less than 11.5 g/dl), 7% for iron deficiency (serum ferritin less than 12 micrograms/l) and 6.6% for iron depletion (serum ferritin 12-20 micrograms/l).

Low-birth-weight infants in the Cape Peninsula. A follow-up study at the age of 3 years.

A sample of coloured children from the Cape Town City Council area who had been of low birth weight, although a weight appropriate for gestational age, was examined at the age of approximately 3 years. The children were compared with a control group of similar social background who had been of normal birth weight. Growth parameters were compared with the National Center for Health Statistics centiles. The low-birth-weight infants had compensated well. Although they were lighter, shorter in stature and had lower intelligence quotient scores than their normal-birth-weight contemporaries, when corrected for prematurity the growth parameters and IQ did not differ significantly from those of the controls. Six per cent of the preterm infants had major and 15% minor handicaps. Infants with very low birth weights (less than 1500 g) had no more handicaps than those with low birth weights. Iron deficiency was detected in 18% of the children overall but all those who were anaemic were from the low-birth-weight groups. Between 1 and 3 years of age the low-birth-weight infants had more illnesses but no more hospital admissions than the controls.

Group B meningococcal infection in children during an epidemic in Cape Town, South Africa.

One hundred and thirteen children with meningococcal infection were studied during an epidemic caused by N. meningitidis group B. Fifteen per cent presented with only meningeal symptoms, the remainder showed signs of septicaemia or combined septicaemia and meningitis. Sixteen per cent of the children were in shock and 18% required admission to the Intensive Care Unit (ICU). The mortality was 4.4%. More than half the children were younger than 2 years old. There was no statistical association between the age or nutritional state of the children and any of our measures of severity. A short history of symptoms was more common in children who presented with septicaemia and severe illness, who needed admission to the ICU, or who died. Diagnosis was confirmed by routine bacteriological methods and counter-immuno-electrophoresis (CIE) in 104 children. Eighty-six per cent of the isolates were group B type 2. A history of recent antibiotic treatment was associated with fewer positive cultures, but detection of meningococcal antigen by CIE was not affected by this. CIE antigen detection was not reliable because of the high incidence of false-negative results.

Ferritin levels in human milk.

Ferritin was detected and quantitated in breast milk from 24 mothers of healthy fullterm infants 3 days, 7 days, 6 weeks and 3 months after delivery. Highest concentrations were found at day 3 and demonstrated a marked decline at day 7, with negligible levels at 6 weeks and 3 months. The values in breast milk were compared with mother's serum ferritin concentration at delivery and a significant but weak correlation (r = 0.475, P less than 0.05) was found between the paired values of maternal serum ferritin at delivery and breast milk ferritin at day 3. The possible biological significance of ferritin in breast milk is discussed.

Complement abnormalities during an epidemic of group B meningococcal infection in children.

During an epidemic of group B meningococcal infection mean values obtained in 96 consecutively affected children showed a reduction in classical pathway function (CH50), normal alternate pathway function (AP50), C4 and factor B levels, and raised C3 levels. CH50, C3 and Factor B were however significantly lower in those children who had a rapid onset of illness, were in shock, had signs of septicaemia, had extensive skin purpura, or who died. The presence of detectable meningococcal antigen by Counter Immuno Electrophoresis (CIE) and laboratory evidence of Disseminated Intravascular Coagulation (DIC) also correlated with lower complement levels. The significant reduction in CH50 and Factor B in the more severely affected patients suggests that activation of both classical and alternate pathways occurs in group B meningococcal infection.