Neurodevelopmental and behavioural outcomes of HIV-exposed uninfected and HIV-unexposed children at 2-3 years of age in Cape Town, South Africa.

Successful vertical HIV transmission prevention programmes (VTP) have resulted in an expanding population of HIV-exposed uninfected (HEU) infants whose growth, health and neurodevelopmental outcomes could have consequences for future resource allocation. We compared neurodevelopmental and behavioural outcomes in a prospective cohort of 2-3 year old HEU and HIV-unexposed uninfected (HU) children.Women living with and without HIV and their infants were enrolled within three days of birth from a low-risk midwife obstetric unit in Cape Town, South Africa during 2012 and 2013, under WHO Option A VTP guidelines. HIV-uninfected children aged 30-42 months were assessed using the Bayley scales of Infant Development-Third edition (BSID) and Strengths and Difficulties questionnaire (SDQ).Thirty-two HEU and 27 HU children (mean birth weight 3048g vs 3096g) were assessed. HEU children performed as well as HU children on BSID cognitive, language and motor domains. Mean scores fell within the low average range. Mothers of HEU children reported fewer conduct problems but stunting was associated with increased total difficulties on the SDQ.HEU and HU children's performance on the BSID was similar. In this low-risk cohort, HIV exposure did not confer additional risk. Stunting was associated with increased behavioural problems irrespective of HIV exposure.

Parietal dysfunction during number processing in children with fetal alcohol spectrum disorders.

Number processing deficits are frequently seen in children prenatally exposed to alcohol. Although the parietal lobe, which is known to mediate several key aspects of number processing, has been shown to be structurally impaired in fetal alcohol spectrum disorders (FASD), effects on functional activity in this region during number processing have not previously been investigated. This fMRI study of 49 children examined differences in activation associated with prenatal alcohol exposure in five key parietal regions involved in number processing, using tasks involving simple addition and magnitude comparison. Despite generally similar behavioral performance, in both tasks greater prenatal alcohol exposure was related to less activation in an anterior section of the right horizontal intraparietal sulcus known to mediate mental representation and manipulation of quantity. Children with fetal alcohol syndrome and partial fetal alcohol syndrome appeared to compensate for this deficit by increased activation of the angular gyrus during the magnitude comparison task.

A tensor-based morphometry analysis of regional differences in brain volume in relation to prenatal alcohol exposure.

Reductions in brain volumes represent a neurobiological signature of fetal alcohol spectrum disorders (FASD). Less clear is how regional brain tissue reductions differ after normalizing for brain size differences linked with FASD and whether these profiles can predict the degree of prenatal exposure to alcohol. To examine associations of regional brain tissue excesses/deficits with degree of prenatal alcohol exposure and diagnosis with and without correction for overall brain volume, tensor-based morphometry (TBM) methods were applied to structural imaging data from a well-characterized, demographically homogeneous sample of children diagnosed with FASD (n = 39, 9.6-11.0 years) and controls (n = 16, 9.5-11.0 years). Degree of prenatal alcohol exposure was significantly associated with regionally pervasive brain tissue reductions in: (1) the thalamus, midbrain, and ventromedial frontal lobe, (2) the superior cerebellum and inferior occipital lobe, (3) the dorsolateral frontal cortex, and (4) the precuneus and superior parietal lobule. When overall brain size was factored out of the analysis on a subject-by-subject basis, no regions showed significant associations with alcohol exposure. FASD diagnosis was associated with a similar deformation pattern, but few of the regions survived FDR correction. In data-driven independent component analyses (ICA) regional brain tissue deformations successfully distinguished individuals based on extent of prenatal alcohol exposure and to a lesser degree, diagnosis. The greater sensitivity of the continuous measure of alcohol exposure compared with the categorical diagnosis across diverse brain regions underscores the dose dependence of these effects. The ICA results illustrate that profiles of brain tissue alterations may be a useful indicator of prenatal alcohol exposure when reliable historical data are not available and facial features are not apparent.

Behavioural and emotional problems in children with intellectual disability attending special schools in Cape Town, South Africa.

A sample of 355 children with intellectual disability (ID) attending special schools in Cape Town, South Africa, were assessed on the Developmental Behavioural Checklist--Teacher Version (DBC-T). A prevalence rate of 31% for psychopathology was found. Boys manifested more behaviour problems than girls, especially in relation to disruptive, self-absorbed and antisocial behaviours. Children with severe and profound levels of ID showed more behavioural difficulties than those in the mild and moderate categories. Specific behaviour problems were self-absorbed and autistic behaviours in children with profound ID, communication problems and anxiety in those with severe ID and antisocial behaviour in children with mild ID. Epilepsy, but not cerebral palsy was associated with higher total behaviour scores. Ambulant children were more disruptive and antisocial, while non-ambulant children were more anxious. Non-verbal children had higher scores on all of the subscales except for disruptive behaviour.

Patterns of cognitive-motor development in children with fetal alcohol syndrome from a community in South Africa.

BACKGROUND: Even though fetal alcohol syndrome (FAS) has been reported in nonwestern nations, there is a paucity of information on neurodevelopment in the affected children from those nations. This article reports on a study of cognitive-motor development in a group of children with FAS from a community in the Western Cape Province in South Africa. METHODS: Thirty-four children with FAS and 34 controls from grade 1 (school entry level) classes participated. The two groups comprised Afrikaans-speaking children of mixed ancestry (South African Colored) and were matched for age, sex, and family income. The Griffiths Mental Development Scales were used to assess cognitive motor development of the participants. RESULTS: A multivariate analysis of covariance was performed to test the group effect on the combined Griffiths subscales adjusting for maternal education. The results showed a significant group effect. Follow-up analyses revealed that a combination of four subscales (Speech and Hearing, Performance, Practical Reasoning, and Eye and Hand Coordination) primarily contributed to the overall effect. Although there was a marginal effect on the Personal-Social subscale, no significant effect on the Locomotor (gross motor) subscale was found. CONCLUSIONS: The results showed that the FAS group was markedly deficient only in higher-order cognitive-motor competencies.

Evaluation of the infant at risk for neurodevelopmental disability.

BACKGROUND: Infants with neurodevelopmental abnormality need to start therapy early, and because of this they should be detected as soon as possible. Currently, no widely accepted method of early evaluation exists. OBJECTIVES: To assess and compare, in terms of predicting neurodevelopmental outcome at 1 year of age: (i) a perinatal risk rating (PRR); (ii) the Dubowitz Neurological Assessment (DNA); and (iii) the Infant Neuromotor Assessment (INA). DESIGN AND SETTING: A prospective neurodevelopmental follow-up study on graduates from the Groote Schuur Hospital (GSH) neonatal intensive care unit (NICU). SUBJECTS: A cohort of 130 consecutive NICU graduates were selected according to high-risk criteria. OUTCOME MEASURES: Each infant was examined at term gestational age on the DNA before discharge, and a PRR was allocated. Study infants were seen again at 18 weeks of age when an INA was done, and at 1 year of age a Griffiths Developmental Assessment and full neurological examination was carried out. RESULTS: All of the 130 infants assessed at term were seen at 18 weeks. Thereafter 5 were lost to follow-up and 2 died. The outcome for the remaining 123 is known. CONCLUSIONS: Prediction of a normal outcome at 1 year of age was 96% on the DNA and 98% for the PRR, but for an abnormal outcome they predicted only 56% and 42%, respectively. The INA done at 18 weeks predicted a normal outcome at 1 year in 99% of cases if 3 or less abnormal signs were present and an abnormal outcome in 82% of cases with 4 or more abnormal signs. Based on these findings a protocol for follow-up of these high-risk infants is suggested.

The value of a scoring system for hypoxic ischaemic encephalopathy in predicting neurodevelopmental outcome.

A numeric scoring system for the assessment of hypoxic ischaemic encephalopathy during the neonatal period was tested. The value of the score in predicting neurodevelopmental outcome at 1 y of age was assessed. Forty-five infants who developed hypoxic ischaemic encephalopathy after birth were studied prospectively. In addition to the hypoxic ischaemic encephalopathy score all but two infants had at least one cranial ultrasound examination. Thirty-five infants were evaluated at 12 months of age by full neurological examination and the Griffiths Scales of Mental Development. Five infants were assessed at an earlier stage, four who died before 6 months of age and one infant who was hospitalized at the time of the 12 month assessment. Twenty-three (58%) of the infants were normal and 17 (42%) were abnormal, 16 with cerebral palsy and one with developmental delay. The hypoxic ischaemic encephalopathy score was highly predictive for outcome. The best correlation with outcome was the peak score; a peak score of 15 or higher had a positive predictive value of 92% and a negative predictive value of 82% for abnormal outcome, with a sensitivity and specificity of 71% and 96%, respectively. For the clinician working in areas where sophisticated technology is unavailable this scoring system will be useful for assessment of infants with hypoxic ischaemic encephalopathy and for prognosis of neurodevelopmental outcome.

Prevalence of neural tube defects in Cape Town, South Africa.

The aim of the study was to document the frequency of neural tube defects (NTD) over a 20-year period in Cape Town and to determine the effects of race, gender, maternal age, parity and season of conception on the prevalence. Multiple sources of ascertainment were used, including all maternity hospital records, neurosurgical and spinal defects clinic data, as well as those from the Human Genetics Department and Fetal Abnormality Group. The prevalence rates for NTD fluctuated between 1.74 and 0.63 per 1,000 births, but showed no significant trends over the 20-year period. Prevalence rates were highest for the white population group of 2.56 per 1,000 births compared to 0.95 per 1,000 for blacks and 1.05 per 1,000 for those of mixed ancestry. The higher rates in the whites, who are of British and European extraction and belong to the more affluent section of the community, would suggest that the possible effects of nutrition and infection are overshadowed by genetic factors. There was a female preponderance for both spinal bifida (M:F ratio 0.89) and anencephaly (M:F ratio 0.67). The highest NTD rates were found at both ends of the maternal age range (< 20 years and > 35 years of age). The prevalence was highest at the extremes of birth order (1.65 and 1.58 for birth order 1 and > 7, respectively, and 0.56 and 0.45 for birth order 5 and 6, respectively). A seasonal variation occurred which differed from that reported for the Northern Hemisphere and may reflect local climatic conditions.

Infants of less than 1250 grams birth weight at Groote Schuur Hospital: outcome at 1 and 2 years of age.

A prospective 2-year follow-up study of infants with birth weights of less than 1250 g was undertaken at Groote Schuur Hospital Neonatal Intensive Care Unit. For a 12-month period beginning July 1988, all live infants born at Groote Schuur Hospital or referred to the Neonatal Intensive Care Unit were included in the study cohort. The aim of the study was to document the morbidity, mortality, and neurodevelopmental outcome of these infants to 2 years of age. Of 235 liveborn infants, 143 (61%) survived to discharge. One hundred twenty-six infants were born weighing less than 1000 g; 42% survived to discharge. One hundred nine infants weighed 1000 g or more at birth, and 83% survived to discharge. Better survival was documented for infants whose mothers attended antenatal care, who weighed more than 900 g, and who were of greater than 30 weeks' gestation. Eleven infants died in the first 6 months after discharge. One hundred six infants (83% of survivors) underwent Griffiths developmental testing and clinical assessment at 1 year of age. Ninety-six (91%) of these survivors were seen and tested at 2 years of age. Of the 106 infants assessed at 1 year of age, 6 infants had cerebral palsy, 6 were globally developmentally delayed without signs of cerebral palsy, and 1 infant showed significant motor delay with a normal developmental quotient. At 2 years of age 1 additional infant had cerebral palsy and 9 more infants are likely to be mentally retarded. At 2 years of age the major handicap rate was, therefore, 22%. Sixty-nine percent of surviving infants, and all but 1 of the infants with cerebral palsy, were underweight for gestational age at birth. There was a tendency for these underweight-for-gestational-age infants to score less well at 2 years of age. Infants who received ventilation and infants with a birth weight of less than 1000 g were not found to score less well than other infants in the cohort.

Preschool development of coloured children in Cape Town.

Developmental screening was applied during infancy to a birth cohort of 1,000 coloured infants born consecutively in Cape Town. The developmental progress of a sample of 187 children randomly selected from the cohort was followed over a period of 5 years. The value of the use of developmental screening is questioned, since 4 of the children in the cohort with major handicap had been diagnosed before the first screening was carried out and a 5th child with deafness was not detected by the screening process. Developmental milestones were similar to those studies reported in the literature. At 12 months the development correlated best with family stability. Language development at 30 months was associated with mother's education and family stability and reflected a general lag in verbal skills. By 5 years there was a good correlation between development and social indicators, particularly income and mother's education.

Growth of preschool coloured children in Cape Town.

The growth of a random sample of coloured children in Cape Town was studied from birth until 5 years. At birth they were relatively light and short for gestational age. Size at birth correlated with social class. A rapid postnatal weight gain rendered them relatively overweight between 3 and 6 months. Thereafter they became lighter and shorter than the NCHS reference values and this persisted throughout the preschool period. Genetic factors, reflected by parental growth, were found to predict growth during childhood, but they were more predictive of weight and head circumference than of length. From 12 months onwards, socio-economic factors played a significant role in determining growth even after the effects of the genetic factors had been taken into account.

Causes of mental handicap in Cape Town.

A cross-cultural study of the cause of the mental handicap of greater than 1,000 children born in the Cape Town area between 1974 and 1986 was carried out. Acquired causes were noted to be more prevalent among the black ethnic group. This study showed that at least 80-100 additional cases of moderate-severe mental handicap can be expected in the Cape Town area each year. Attention is drawn to the expanded facilities that will be required to provide for the ongoing special needs of these children. Possible areas for prevention of mental handicap are discussed.

Evaluation of preschool children with Down's syndrome in Cape Town using the Griffiths Scale of Mental Development.

Fifty-five preschool children with Down's syndrome were assessed using the Griffiths Scale of Mental Development. They were all the children with Down's syndrome living in Cape Town who spoke English or Afrikaans as their home language. There was a significant decrease in developmental quotient with increasing age and the hearing and speech subscore was lower than the other subscores. No significant associations were found between maternal age, sex, social class or race of the child and development. There was a negative association between developmental quotient and the number of siblings. The additional stimulation of a playgroup or preschool centre was associated with improved developmental functioning when compared to the children cared for at home during the day.

Postneonatal mortality in the Matroosberg Divisional Council area of the Cape Western Health Region.

Postneonatal deaths in the Matroosberg Divisional Council area were studied with particular reference to social and nutritional factors. Adverse social circumstances were strongly associated with death during the first year of life. The children who died had fathers who were less educated and held lower rated jobs than fathers of children in a control group. They were less likely to have belonged to a nuclear family and were more likely to have had families with social problems. They were also more frequently bottle-fed, were more likely to have been underweight, and were less often fully immunised. The study illustrates the need for a GOBI-FFF intervention strategy in the area.

Early childhood mortality in Cape Town.

Early childhood mortality in the City of Cape Town was investigated with particular reference to preventability. Deaths were considered preventable if they resulted from infections or other acquired diseases and accidents. Non-preventable deaths were those resulting from congenital disorders, neoplastic disease and other non-acquired conditions. Cot deaths formed a third group. Mothers in the preventable group had had more pregnancies than those in the non-preventable group, and the children who died were more likely to have been born prematurely than children in the non-preventable group. Children in the preventable group came from lower social class backgrounds than those in the non-preventable group and were more frequently from single-parent families who lived with extended family or with people who were not related to them. Their families were less likely to own their own homes than families of children in the non-preventable group. The children who died had more siblings, more of whom had died previously, than children in a control group. The cot death group did not differ from the preventable group, but did differ from the non-preventable group with regard to gestational age and paternal occupation. The study shows that preventable deaths were particularly associated with socio-economic disadvantage.

A comparative study of postnatally-acquired cerebral palsy in Cape Town.

The importance of socio-economic conditions in the causation of postnatally-acquired cerebral palsy has not been stressed in previous studies. A comparative survey was undertaken in Cape Town, South Africa. Three ethnic groups were compared--white, coloured (mixed ancestry) and black. The percentage of postnatally-acquired cerebral palsy in these groups was 13.2, 24.0 and 36.1 per cent, respectively. These figures can be explained by the differing socio-economic conditions of each group, the white group belonging to the highest socio-economic stratum and the black group to the lowest. The main causes of postnatally-acquired cerebral palsy were cerebral infections (particularly meningitis), cerebral trauma and cerebrovascular accidents. The proportion in each group, the main causal factors, age at onset, types of cerebral palsy and intellectual status are similar to those of most previous studies.

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.

Tuberculous meningitis in children in the Western Cape. Epidemiology and outcome.

The incidence of tuberculous meningitis in children was determined using hospital records as well as local authority notifications. One hundred and eighty-five cases occurred over a 3-year period. The age-specific incidence in the 0-14-year-old group was 7,5/100 000. In only 28 cases was the disease at an early stage when treatment was commenced. Young age and late-stage disease at presentation were associated with a poor outcome. The associated morbidity and mortality rates were high; the mortality rate was 24%, and nearly 50% of patients were left with a residual disability.

Tactile aversion in infancy.

Twenty children referred for assessment of delay in gross motor development showed tactile aversion. This is a common cause of delay in motor development and may be misdiagnosed as cerebral palsy or as a global developmental retardation. In some infants feeding is a problem. Although the condition is self-limiting, many patients need orthopaedic treatment for abnormalities of foot posture when they start to walk.