Human immunodeficiency virus infection, diarrheal disease and sociodemographic predictors of child growth.

AIM: To compare growth patterns between human immunodeficiency virus (HIV)-infected and -uninfected preschool children. To examine the associations between diarrheal and respiratory infections, sociodemographic factors and growth. METHODS: A longitudinal study was conducted among 524 children who were 6-60 mo of age at recruitment. Information on sociodemographic characteristics was collected at baseline from the caregiver. Hemoglobin, malaria infection and HIV status of the children were assessed from a blood sample. Monthly height (length if <24 mo) and weight measurements were obtained, and clinical assessments carried out, during an average 12 mo follow-up period. Yearly increments in height and weight were compared by HIV status, incidence of diarrhea and respiratory infections, and levels of sociodemographic variables. RESULTS: After adjusting for maternal education, anemia and vitamin A supplementation, HIV infection was related to 2.8 cm [95% confidence interval (95% CI) 0.6, 5.0] and 1.3 kg (95% CI 0.0, 2.5) lower yearly length and weight gains, respectively, in children who were between 6 and 11 mo old at baseline. Among children who were 12-23 mo old at recruitment, HIV infection was associated with 0.6 kg (95% CI 0.1, 1.0) less yearly weight gain. HIV infection was not related to linear or ponderal growth in children >24 mo old. Maternal illiteracy, severe child anemia and episodes of acute diarrhea were additional risk factors for growth delay in length. CONCLUSION: HIV infection is associated with linear and ponderal growth retardation in children aged <24 mo. Additional predictors of linear growth retardation include preventable conditions such as poor maternal education, child anemia and diarrheal disease.

Perinatal Risk Factors for Neonatal Bleedind at the Muhimbili National Hospital Dar-es-Salaam; Tanzania

This incident case-control study of bleeding neonates in a Baby Friendly Hospital was done to obtain the prevalence and risk factors associated with bleeding disorders in the neonatal unit. During a 4-month period from August to November 1998; 175 out of 1628 admitted infants were found to have some sort of bleeding. These were compared with 414 control infants. Prematurity; Low Birth Weight; Caesarian Section and anesthesia; and presence of asphyxia were significantly associated with bleeding. The Prothrombin and Activated Partial thromboplastin Test were not significantly altered in bleeding infants and had a poor correlation with clinical presence of a bleeding disorder.The low prevalence of bleeding disorder and coagulation defects is discussed and suggested that Breast Feeding may not be a risk factor for bleeding disorder in this unit. Further studies are needed in this regard

Verbal autopsy in establishing cause of perinatal death.

INTRODUCTION: Perinatal mortality is a sensitive indicator of health status of a community and is also highly amenable to intervention. The causes of perinatal deaths in developing countries are often difficult to establish. Verbal autopsy has been used in several countries for children and adults, but seldom for perinatal cause. OBJECTIVE: To establish the cause of perinatal deaths using verbal autopsy. DESIGN: Community-based cross-sectional, retrospective study to identify perinatal death over a one year period from July 1996-June 1997. Comparison was made with hospital records. An algorithm of signs and symptoms was used by trained personnel to identify the cause of perinatal death. The duration of collection of data was six months (August 1996-January 1997). SETTING: Hai district of Kilimanjaro region in Tanzania. SUBJECTS: All perinatal deaths within one year. RESULTS: The perinatal mortality was 58 per 1000 (121 deaths and 2088 live births). Verbal autopsy could establish the cause of death in 105 of the 121 deaths. Hospital records showed 79 deaths indicating that 42 deaths probably occurred at home. Among the 79 available hospital records, the cause of death could be established in only 30 (38%). The causes of postnatal death were compared between the verbal autopsy and hospital records. There was a good correlation between the same, however only 18 records were available from hospital among the total 31 postnatal deaths. The specificity of determining cause of death using verbal autopsy was 100% and sensitivity 61%. CONCLUSION: The commonest causes of perinatal deaths were related to obstetric care, therefore interventions to curb perinatal mortality should be directed to improvement of obstetric care. Verbal autopsy is a simpler and more sensitive tool in establishing the cause of perinatal death than hospital records in a rural district of Tanzania. Large-scale studies are needed to validate this.

Detection of congenital malaria by polymerase-chain-reaction methodology in Dar es Salaam, Tanzania.

The examination of congenital malaria was performed by Giemsa staining and polymerase-chain-reaction (PCR) methodology. We randomly selected 298 neonates who had been admitted to Muhimbili Medical Center (MMC) at Dar es Salaam, Tanzania. One baby among all the enrolled neonates was recognized as having a congenital malaria infection, which gave a prevalence of 0.33%. The present result was 5-fold the clinically recognized prevalence of congenital infection with malaria in the ward. The PCR method identified two cases, one of which was negative as determined by the Giemsa-staining method. Therefore, the PCR method was useful for the detection of scant amounts of malarial parasites in numerous blood samples. The screening of malaria by a sensitive PCR method contributes to reduce the mortality of asymptotic neonates in particular.

A randomized trial of vitamin A supplements in relation to mortality among human immunodeficiency virus-infected and uninfected children in Tanzania.

OBJECTIVES: To determine whether vitamin A supplements result in reduced mortality among HIV-infected and uninfected children. DESIGN: Randomized, double blind, placebo-controlled trial. METHODS: Starting in April, 1993, we randomized 687 children age 6 months to 5 years who were admitted to the hospital with pneumonia. Children who were severely malnourished or had clinical signs of vitamin A deficiency were excluded. At baseline children received placebo or 400 000 IU (or half that for infants) of vitamin A, in addition to standard treatment for pneumonia. They received further doses of the same regimen 4 and 8 months after hospital discharge. Sera from children were tested for HIV antibodies by enzyme-linked immunosorbent assay and Western blot tests. For positive children <15 months of age, HIV infection was confirmed by amplified heat-denatured HIV-p24 antigen assays with confirmatory neutralization assays. HIV status was ascertained for 648 of 687 enrolled children. The mean duration of follow-up was 24.4 months (SD = 12.1). RESULTS: Of 648 children 58 (9%) were HIV-infected. Compared with uninfected children, all-cause mortality was higher among HIV-infected children, as was mortality caused by pneumonia or diarrhea (P < 0.001 for each). Overall vitamin A supplements resulted in a 49% reduction in mortality [relative risk (RR), 0.51; 95% confidence interval (CI), 0.29 to 0.90, P = 0.02]. Vitamin A supplements reduced all-cause mortality by 63% among HIV-infected children (RR 0.37; CI 0.14 to 0.95, P = 0.04) and by 42% among uninfected children (RR 0.58, CI 0.28 to 1.19, P = 0.14). Vitamin A supplements were also associated with a 68% reduction in AIDS-related deaths (P = 0.05) and a 92% reduction in diarrhea-related deaths (P = 0.01). CONCLUSION: Vitamin A deficiency, which is common among children in many developing countries, is particularly severe among HIV-infected children. Our findings indicate that vitamin A supplements, a low cost intervention, reduce mortality of HIV-infected children.

A high prevalence of metabolic bone disease in exclusively breastfed very low birthweight infants in Dar-es-Salaam, Tanzania.

Metabolic bone disease (MBD), or rickets, is common in very low birthweight infants. A descriptive, cross-sectional, hospital-based study was carried out at Muhimbili Medical Centre, Dar-es-Salaam from 15 April to 30 June, 1995 to discover the magnitude, contributory factors, morbidity and suitable biochemical diagnostic tests for MBD. One hundred infants with a postnatal age of 6-12 weeks, whose birthweights were 1500 g or less were studied. Thirty-three of 100 (33%) infants, 16 boys and 17 girls, were radiographically diagnosed as having metabolic bone disease. The mean (SD) gestational age of those infants was 30.4 (2.7) weeks, while that of the infants without metabolic bone disease was 32.4 (3) weeks (p = 0.003). There was no significant difference in birthweight, serum calcium and serum phosphate levels between those infants with MBD and those without. The mean (SD) serum alkaline phosphatase in infants with MBD was 1052.9 (493.3) U/l and 766.8 (301.7) in those without MBD (p = 0.006). Thus, metabolic bone disease is common in very low birthweight infants. Wrist radiography and serum alkaline phosphatase levels remain important diagnostic tools. MBD should be considered seriously in very low birthweight infants.

Vitamin A supplementation and severity of pneumonia in children admitted to the hospital in Dar es Salaam, Tanzania.

Vitamin A deficiency and acute lower respiratory tract infections coexist as important public health problems in many developing countries. We carried out a randomized, double-blind, placebo-controlled trial to examine whether large doses of vitamin A given to Tanzanian children who are admitted to the hospital with nonmeasles pneumonia would reduce the severity of respiratory disease. Six hundred eighty-seven children were randomly assigned to receive either placebo or vitamin A [200 000 IU (60 mg retinol equivalents) for children > 1 y of age and 100000 IU (30 mg retinol equivalents) for infants] on the day of admission and another dose on the following day. Of the 346 children in the vitamin A group, 13 died in the hospital, compared with 8 of 341 children in the placebo group; the relative mortality was 1.63 (95% CI: 0.67, 3.97; P = 0.28). The mean number of days of hospitalization was the same in both groups (4.2 d). There were no differences between the vitamin A and placebo groups in the duration of hospital stay when examined within categories of children stratified by age, sex, breast-feeding status, nutritional status at baseline, or quartile of dietary vitamin A intake in the 4 mo before admission to the hospital. There were also no differences in the mean number of days of fever, rapid respiratory rate, or hypoxia, whether these endpoints were examined in the total number of subjects or in a subset with more severe clinical conditions at baseline. Large doses of vitamin A had no protective effect on the course of pneumonia in hospitalized Tanzanian children.

Nosocomial bacterial infections among children with severe protein energy malnutrition.

The incidence of hospital acquired acute bacterial infections among 164 severely malnourished children admitted to the paediatric wards at the Muhimbili Medical Centre in Dar es Salaam were studied. On admission, ninety two per cent of the patients had at least one form of bacterial infection. During the subsequent two weeks hospital stay, 49% of the patients acquired a new infection. Septicaemia and urinary tract infection (UTI) were the commonest infections. Staphylococcus aureus was the commonest organism in the former, while gram negative organisms, Escherichia coli and Klebsiella species, were predominant in the latter. Pathogens similar to those found from patients were cultured from random samples taken from the floor, beds, towels, sinks and antiseptic containers in the wards. Sensitivity patterns of isolated pathogens to antimicrobial agents showed that S. aureus was highly sensitive to cloxacillin, erythromycin, and gentamicin, while the gram negative organisms were highly sensitive to gentamicin. Our study shows that the problem of nosocomial infection in paediatric wards requires urgent attention. There is a need to institute preventive measures including provision of proper nursing care, maintenance of sterile environment, and reduction of duration of hospital stay.

PIP: The incidence of hospital acquired acute bacterial infections among 164 several malnourished children admitted to the pediatric wards at the Muhimbili Medical Centre in Dar es Salaam, Tanzania, were studied. On admission, a thorough physical examination and blood and urine cultures were done on each child. Cultures from ears, throat, skin, rectum, or stools were taken. 89 (54%) were males and 75 (46%) were females with an age range of 2-59 months. 90 (55%) had marasmus, 39 (24%) had kwashiorkor, and 35 (21%) had marasmic-kwashiorkor. On admission, 32 (82%) of the kwashiorkor cases and 88 (98%) of the marasmus cases had at least 1 bacterial infection (p 0.05), a statistically significant difference. The children were followed up for 2 weeks when repeat blood and urine cultures were done for all. Antibiotic sensitivity was determined by the single disc diffusion method for antimicrobial agents used (penicillin, ampicillin, erythromycin, gentamicin, cloxacillin, chloramphenicol, contrimoxazole, nitrofurantoin, and sulphonamide). Samples were taken from randomly selected sites in the wards: 20 from floors, 20 from sinks, 20 from towels, 20 from beds, and 20 from antiseptic container. By the end of their stay in the hospital, 80 (49%) of the patients had acquired a nosocomial infection. 24 (62%) kwashiorkor cases had a nosocomial infection, while 15 (44%) of marasmus-kwashiorkor as well as 41 (45%) of the marasmus patients had such an infection. 72% of female patients were at a higher risk of acquiring an infection compared with the males (46%) (P 0.05). E. coli and Klebsiella species were the most frequently detected organisms in urine, while Staphylococcus aureus was most common in blood. Of the 100 specimens taken from the wards, 38 yielded S. aureus, 26 yielded Klebsiella species, 10 had Streptococcus faecalis, and 4 had E. coli. Erythromycin, cloxacillin, and gentamicin had a strong effect against s. aureus. Klebsiella species and E. coli were completely sensitive to gentamicin. All 10 isolates of S. faecalis from the wards were sensitive to ampicillin, erythromycin, and penicillin.

Morbidity and mortality among low birth weight infants in Muhimbili medical centre; Dar es Salaam; Tanzania

In this paper we present and discuss the problems of low birth weight infants. Although we did not have a control group of normal babies it seems from our results that LBW babies are particularly prone to health problems as 34.5 percent of the cases admitted to the neonatal unit were morbid

Tetanus neonatorum--experience with intrathecal serotherapy at Muhimbili Medical Centre, Dar es Salaam, Tanzania.

In an attempt to lower the mortality rate of neonatal tetanus a study was undertaken to determine whether intrathecal serotherapy influences mortality from this disease. Sixty-six babies with tetanus neonatorum were studied. The mortality rate among babies who received intrathecal anti-tetanus serum (ATS) was 45% compared with 82% in the control group given intramuscular ATS (P congruent to 0.002). Infants who received intrathecal ATS also had fewer complications than controls (P less than 0.001) and the duration of hospital stay for the survivors was 19.3 days compared with 28.7 days for the control group (P less than 0.05). It is concluded that intrathecal ATS is superior to intramuscular ATS in the treatment of neonatal tetanus.

Peripheral lymphadenopathy in children in Dar es Salaam, Tanzania. A study from biopsy material.

Children are commonly brought to the primary physician because of palpable peripheral lymph nodes. In order to determine the common causes 257 excisional peripheral lymph node biopsies of children between four days and 15 years of age were analysed. The diagnoses made were: tuberculous lymphadenitis (67.3%), non-specific reactive lymphadenitis (20.6%), malignant neoplasm (11.3%) and histiocytosis-X (0.8%). Fifty percent of the children with tuberculous lymphadenitis were less than five years of age. Of the neoplasms Hodgkin's disease was the commonest (34.5%).

Factors associated with low birth weight in the population of Dar es Slaaam, Tanzania.

Factors associated with low birthweight in Dar es Salaam have been evaluated. The incidence of low birthweight is higher among female infants and infants belonging to parents of a low socioeconomic status. Primiparity, short stature of the mother, a multiple pregnancy, "toxaemia" of pregnancy are some of the factors influencing the growth velocity of the foetus leading to an increased indidence of small-for-dates infants. Low maternal age and antepartum haemorrhage mainly affect the duration of gestation and lead to a preponderance of preterm appropriate-for-gestational-age infants. However, in 66% of the mothers with low birthweight infants no associated maternal complication of the pregnancy could be detected.

Intrauterine growth of live-born Tanzanian infants.

The incidence of low birthweight infants, the effect of intrauterine growth retardation on anthropometric measurements, and local standards of intrauterine growth curves for weight, crown-heel length and head circumference together with curves of body measurement ratios of weight/length, weight/head circumference and weight/length x head circumference are presented for the population of Dar es Salaam (Tanzania). Acomparison is made with a standard composed for a Caucasian community with completely different socio-economic and nutritional status. From 28 to 34 weeks of gestation weight gain in Dar es Salaam foetuses was reduced, while length and head circumference were relatively less affected. However, an increased intrauterine growth velocity was recorded from 34 to 38 weeks of gestation.

PIP: A prospective study on the incidence of low birthweight infants, the effect of intrauterine growth retardation on anthropometric measurements, and local standards of intrauterine growth curves for various body measuremenst was conducted at Dar es Salaam, Tanzania. The study involved 16,532 consecutive live born infants. The mean birthweight at term was calculated from 200 randomly-selected infants in the group. The scheme, i.e., measurements and visible signs, used to determine gestational age is presented in tabular form. Grown-heel length, head circumference, weight/length ratio, weight/head circumference ratio, and weight/length x head circumference measurements and calculations were made. These measurements were charted against gestational age in order to draw an intrauterine growth chart. A comparison was made between these standards and the bodyweight standards for a different socioeconomic and nutritional status population in Montreal. The incidence of low birthweight infants was 1,111 male and 1,396 female infants out of the total of more than 16,000. The intrauterine growth chart showed that weight gain was reduced from 28-34 weeks gestation, but length and head circumference were less affected. From 34-38 weeks gestation, intrauterine growth increased. All measurements for the more socioeconomically advantaged Montreal population were greater. Implications of this study are still under consideration.