Data-driven malaria prevalence prediction in large densely populated urban holoendemic sub-Saharan West Africa.

Over 200 million malaria cases globally lead to half-million deaths annually. The development of malaria prevalence prediction systems to support malaria care pathways has been hindered by lack of data, a tendency towards universal "monolithic" models (one-size-fits-all-regions) and a focus on long lead time predictions. Current systems do not provide short-term local predictions at an accuracy suitable for deployment in clinical practice. Here we show a data-driven approach that reliably produces one-month-ahead prevalence prediction within a densely populated all-year-round malaria metropolis of over 3.5 million inhabitants situated in Nigeria which has one of the largest global burdens of P. falciparum malaria. We estimate one-month-ahead prevalence in a unique 22-years prospective regional dataset of > 9 × 104 participants attending our healthcare services. Our system agrees with both magnitude and direction of the prediction on validation data achieving MAE ≤ 6 × 10-2, MSE ≤ 7 × 10-3, PCC (median 0.63, IQR 0.3) and with more than 80% of estimates within a (+ 0.1 to - 0.05) error-tolerance range which is clinically relevant for decision-support in our holoendemic setting. Our data-driven approach could facilitate healthcare systems to harness their own data to support local malaria care pathways.

Skin pH and Transepidermal Water Loss Values in Children with Diaper Dermatitis in Ibadan, Nigeria.

BACKGROUND/OBJECTIVES: Diaper dermatitis (DD) is one of the most common skin conditions in infants and young children. Among the factors associated with greater frequency of DD are high skin pH and transepidermal water loss (TEWL). This study examined the prevalence of DD in healthy black children in Nigeria and evaluated the association between skin surface pH, TEWL, and DD in this population. METHODS: The study was cross-sectional in design and involved children younger than 2 years attending eight immunization clinics in Ibadan, Nigeria (N = 424). Children were recruited into the study using multistage sampling. Information collected included sociodemographic data, diapering and feeding practices. Physical examination of the diaper area was performed on each child to determine whether dermatitis was present. TEWL and skin pH were measured on the anterior chest wall and gluteal areas of each child. RESULTS: A total of 165 (38.9%) children had clinical evidence of DD. The mean skin pH and TEWL values were higher in the gluteal area than the anterior chest wall in all subjects, with or without dermatitis. The mean skin pH and TEWL were significantly higher on the anterior chest wall and in the gluteal area in children with DD. CONCLUSION: In Nigerian children with DD, skin pH and TEWL are higher in the diaper area and at an unaffected skin site.

Blood Transfusion-Associated HIV Infection in Children in Ibadan, Nigeria.

INTRODUCTION: This study describes the epidemiologic features and clinical course of children with blood transfusion-associated HIV infection (TAHI) in Ibadan, Nigeria. METHODOLOGY: All children diagnosed to have TAHI at the University College Hospital, Ibadan, were studied and compared with children who acquired HIV vertically using the pediatric HIV database in the hospital. RESULTS: Transfusion-associated HIV infection accounted for 14 (2.3%) of the 597 children diagnosed to have HIV infection between January 2004 and December 2011. The mean age at diagnosis of TAHI was 10.2 years and that of vertically acquired HIV infection was 3.9 years ( P < .001). In 9 cases, blood transfusion took place in private hospitals and in 5 cases in public hospitals. Median interval between infection and diagnosis of AIDS was 84 months in cases with TAHI and 48 months in vertically acquired cases ( P = .542). CONCLUSION: Optimal blood safety practices are advocated for prevention of TAHI in Nigeria.

Mucocutaneous Disorders of Pediatric HIV in South West Nigeria: Surrogates for Immunologic and Virologic Indices.

OBJECTIVES: Nigeria has the world's highest burden of pediatric HIV. In the face of paucity of monitoring tests in Nigeria, we studied the spectrum of pediatric mucocutaneous manifestations and evaluated their clinical utility as surrogate markers for immunodeficiency and plasma viral load levels. METHODS: Cross-sectional study comparing mucocutaneous manifestations in 155 HIV-positive children aged 12 weeks to 14 years with 155 HIV-negative children. Relationships between mucocutaneous manifestations in HIV-infected patients and their immunologic and virologic indices were analyzed. RESULTS: Mucocutaneous lesions were seen in 53.5% of HIV-infected children compared with 18.1% of the controls. Prevalence of lesions increased with worsening levels of immunodeficiency and increasing viral loads (P < .01). Oral candidiasis, angular stomatitis, and fluffy hair were associated with more severe degrees of immunodeficiency. CONCLUSION: Mucocutaneous disorders are common in HIV-infected children. Oral candidiasis and nutritional dermatoses can be used as surrogates for advanced or severe immunodeficiency.

Comparison of auditory brainstem response in HIV-1 exposed and unexposed newborns and correlation with the maternal viral load and CD4+ cell counts.

OBJECTIVE: The effects of maternal HIV infection and antiretroviral therapy on hearing of HIV-exposed newborns in sub-Saharan Africa have not been investigated. We determined the prevalence of sensorineural hearing loss among HIV-exposed newborns and the association between the hearing threshold and maternal and newborn parameters. DESIGN: A cohort audiometric study of newborns between October 2012 and April 2013. SETTINGS: A secondary and tertiary hospital-based study. PARTICIPANTS: Consecutive 126 HIV-exposed and 121 HIV-unexposed newborns. INTERVENTION: Hearing screening of the newborns was done with Auditory Brainstem Response and compared with maternal HAART, CD4 cell counts, RNA viral loads and newborn CD4 cell count percentage. MAIN OUTCOME MEASURE: Hearing threshold levels of both groups were measured and analysed. RESULTS: Around 11.1% of HIV-exposed and 6.6% of unexposed newborns had hearing impairment (P = 0.2214). About 6.4% of HIV-exposed and 2.5% HIV-unexposed newborns had hearing threshold of more than 20 dBHL (P = 0.1578). There was no significant association between the hearing thresholds of HIV-exposed newborns and maternal CD4 cell counts (P = 0.059) but there was with maternal viral load (P = 0.034). There was significant difference between the hearing thresholds of HIV-exposed newborns with CD4% of 25 or less and more than 25. This study showed significant difference in the hearing of the 119 HAART-exposed newborns and seven unexposed newborns [P = 0.002; risk ratio, 0.13 (0.05-0.32)]. CONCLUSION: There was a trend towards more hearing loss in HIV-exposed newborns. However, hearing thresholds increase with increasing mothers' viral load. The background information supports the need for further studies on the role of in-utero exposure to HIV and HAART in newborn hearing loss.

Circulatory hepcidin is associated with the anti-inflammatory response but not with iron or anemic status in childhood malaria.

Cerebral malaria (CM) and severe malarial anemia (SMA) are the most serious life-threatening clinical syndromes of Plasmodium falciparum infection in childhood. Therefore, it is important to understand the pathology underlying the development of CM and SMA as opposed to uncomplicated malaria (UM). Increased levels of hepcidin have been associated with UM, but its level and role in severe malarial disease remains to be investigated. Plasma and clinical data were obtained as part of a prospective case-control study of severe childhood malaria at the main tertiary hospital of the city of Ibadan, Nigeria. Here, we report that hepcidin levels are lower in children with SMA or CM than in those with milder outcome (UM). While different profiles of pro- and anti-inflammatory cytokines were observed between the malaria syndromes, circulatory hepcidin levels remained associated with the levels of its regulatory cytokine interleukin-6 and of the anti-inflammatory cytokine inerleukin-10, irrespective of iron status, anemic status, and general acute-phase response. We propose a role for hepcidin in anti-inflammatory processes in childhood malaria.

Oral lesions and their association with CD4 count and viral load in HIV positive Nigerian children.

BACKGROUND: ral lesions may indicate the presence of HIV infection and may differ in children and adults in different regions. AIM: To determine the prevalence, types of oral lesions in HIV positive children and their association with the clinical stage, CD4 count and viral load. METHODS: A cross-sectional study involving consecutive HIV positive children whose sero-positive status was confirmed with ELISA screening and Western immunoblot. Oral lesions were diagnosed clinically by a trained dental surgeon using previously established classification. Data obtained was analyzed with SPSS 15.0. RESULTS: There were 127 children with age range of 3 to 204 months (median: 60 months) and male preponderance of 58.3% (n=74). 55.9% (n=71) of the subjects had oral lesions and pseudomembranous candidiasis (55.9%) was the commonest followed by caries (12.7%), xerostomia (7.8%) and gingivitis (6.9%). Correlation between prevalence of oral lesions and clinical stage of the disease did not reveal any statistically significant association (p=0.354). Also there is no statistically significant difference in prevalence of oral lesions between children on Antiretroviral Therapy (ART) and those who are not on ART (p=0.875). Incidence of oral lesions was however associated with lower mean baseline CD4 count (p= 0.004) but not with mean log10 viral load (p=0.256). CONCLUSION: This study has shown that HIV associated oral lesions are prevalent in our environment and antiretroviral therapy does not have significant correlation with occurrence of these lesions in HIV infected children. CD4 count is a better indicator of disease progression than viral load.

Severe childhood malaria syndromes defined by plasma proteome profiles.

BACKGROUND: Cerebral malaria (CM) and severe malarial anemia (SMA) are the most serious life-threatening clinical syndromes of Plasmodium falciparum infection in childhood. Therefore it is important to understand the pathology underlying the development of CM and SMA, as opposed to uncomplicated malaria (UM). Different host responses to infection are likely to be reflected in plasma proteome-patterns that associate with clinical status and therefore provide indicators of the pathogenesis of these syndromes. METHODS AND FINDINGS: Plasma and comprehensive clinical data for discovery and validation cohorts were obtained as part of a prospective case-control study of severe childhood malaria at the main tertiary hospital of the city of Ibadan, an urban and densely populated holoendemic malaria area in Nigeria. A total of 946 children participated in this study. Plasma was subjected to high-throughput proteomic profiling. Statistical pattern-recognition methods were used to find proteome-patterns that defined disease groups. Plasma proteome-patterns accurately distinguished children with CM and with SMA from those with UM, and from healthy or severely ill malaria-negative children. CONCLUSIONS: We report that an accurate definition of the major childhood malaria syndromes can be achieved using plasma proteome-patterns. Our proteomic data can be exploited to understand the pathogenesis of the different childhood severe malaria syndromes.

Haemoglobinuria among children with severe malaria attending tertiary care in Ibadan, Nigeria.

BACKGROUND: Haemoglobinuria is one of the manifestations of severe malaria and results from severe intravascular haemolysis. Glucose-6-phosphate dehydrogenase (G6PD) deficiency has been implicated in its aetiology. Haemoglobinuria may be associated with severe anaemia and, less frequently, acute renal failure. METHODS: A prospective case-control study was carried out to determine the incidence of haemoglobinuria as confirmed by dipstick urinalysis, microscopy and spectrophotometric measurement, among children with severe malaria. A total of 251 children presenting at the Children's Emergency Ward with severe malaria were recruited over a period of 21 months. The G6PD status and the outcomes of severe malaria in children with and without haemoglobinuria was studied with respect to renal failure, the recurrence of haemoglobinuria and blood pressure changes over a three-month follow-up period. RESULTS: It was found that the incidence of haemoglobinuria among children with severe malaria is 19.1%. Children <5 years constituted 76.8% of all the study patients. Patients with haemoglobinuria had median age of 52.5 months, which was significantly higher than 35 months in patients without haemoglobinuria (p=0.001). Although, haemaglobinuria was commoner among boys (54.2%) than girls (45.8%), the difference was not statistically significant. There were no significant differences between children with and without haemoglobinuria regarding their nutritional status or parasite densities. Among the clinical features of the study patients, only jaundice was significantly associated with haemoglobinuria (p=0.0001). Renal failure occurred in three out of 48 children with haemoglobinuria and in none of the 203 without. There was not recurrence of haemoglobinuria in the follow-up period. At discharge, blood pressure was elevated in six children (one previously haemoglobinuric), but all returned to normal within the follow-up period. CONCLUSIONS: Haemoglobinuria was a prominent feature of severe malaria and it was significantly associated with jaundice at presentation. Haemoglobinuria was commoner in older children than younger children but not related to sex. G6PD deficiency was not an independent predictor of the occurrence or outcome of haemoglobinuria. Blood pressure was not affected by haemoglobinuria on admission nor during follow-up.

Prevalence and clinical pattern of paediatric HIV infection at the University College Hospital, Ibadan, Nigeria: a prospective cross-sectional study.

BACKGROUND: The prevalence of Paediatric HIV infection is largely unknown in many countries in sub-Saharan Africa. This study was aimed at determining the prevalence, clinical pattern of HIV infection and outcome among new patients aged <15 years using age-specific diagnostic methods. METHODS: A prospective cross sectional study was carried out using the provider initiated HIV testing and counselling (PITC) model. HIV rapid test in parallel was used for screening and confirmation was with HIV DNA PCR in children <18 months and Western Blot in children ≥ 18 months. RESULTS: A total of 600 children were enrolled with ages ranging between one day and 179 months. Male: female ratio was 1.2:1. HIV seroprevalence was 12.3% and after confirmatory tests, the prevalence was 10%. Fourteen (37.8%) of the children aged less 18 months were exposed but not infected. Mother-to-child transmission accounted for 93.3% of cases. Features predictive of HIV infection were diarrhoea, cough, weight loss, ear discharge generalized lymphadenopathy, presence of skin lesions, parotid swelling and oral thrush. About 75% presented in advanced or severe clinical stages of the disease, 56.8% had severe immunodeficiency while 50% had viral loads more than 100,000 copies/ml. Mortality rate was 14.3% among HIV positive compared with 11.3% in HIV negative children but was not significant. Among the HIV positive children, 26.7% were orphans. CONCLUSIONS: The prevalence rate of HIV infection among new patients screened using the PITC model was high, majority resulting from mother-to-child transmission. Most children presented in advanced stages of the disease and mortality rate among them was high. Though, the study site being a referral centre might have contributed to the high prevalence observed in this study, there is a need to expand access to PMTCT services, ensure implementation of PITC in paediatric settings and expand support services for HIV infected children.

Disclosure of HIV status to infected children in a Nigerian HIV Care Programme.

With increasing survival of HIV-infected children, parents face the challenges of disclosure to the children. The aim of this study was to assess the rate of HIV disclosure to children in Ibadan and the factors influencing it in order to guide design of strategies for successful disclosure. A semi-structured questionnaire was administered to consecutive consenting caregivers of HIV-infected children aged ≥6 years attending the Paediatric Infectious Disease Clinic of the University College Hospital, Ibadan, between November 2008 and October 2009. Caregivers of 96 children (46 boys, 50 girls) infected with HIV were interviewed. The ages of the children ranged from 6 to 14 years with a mean (SD) of 8.8 (2.2) years. Disclosure had been done in only 13 (13.5%) of the children; ages at disclosure ranged from 4.5 to 13 years with a mean of 8.7 (SD = 2.2). Disclosure was associated with age above 10 years. Reasons given by carers for non-disclosure in 83 caregivers included inability of the children to understand in 53 (63.9%), fear of disclosure to other children 34 (41.0%), fear of disclosure to family/friends in 28 (33.7%), fear of psychological disturbance of the children in 26 (31.3%) and fear of blaming the parents in 22 (26.5%). Twenty (20.8%) of the children have asked questions relating to their diagnosis and the responses are often evasive. Caregivers felt disclosure had helped adherence to antiretroviral therapy in 7 (63.6%) of the 11 children on antiretroviral drugs in whom there was disclosure but no effect on the remaining. There is a need to assist parents and health care providers in successfully disclosing HIV status to infected children without adverse consequences.

Clinical and Immunological Profile of Pediatric HIV Infection in Ibadan, Nigeria.

In spite of the increasing number of children living with HIV in Nigeria, published data on their clinical profile are few. We describe the clinical profile at presentation of HIV-infected children at the University College Hospital, Ibadan, in a prospective study. Among 272 children studied (149 [54.8%] males; mean age 4.2 years [range 2 months to 15 years]), infection was acquired through vertical transmission in 252 (92.6%), blood transfusion in 5 (1.80%), and undetermined routes in 15 (5.5%) cases. Clinical features included weight loss (62.5%), prolonged fever (55.4%), generalized lymphadenopathy (48.6%), chronic cough (45.4%), and persistent diarrhea (28.3%). Tuberculosis was present in 45.3%, World Health Organization (WHO) clinical stages 3 and 4 disease in 70.6% and severe immunosuppression in 44.5% of cases. Pediatric HIV in Ibadan is acquired mainly vertically and most cases present with severe disease. Improved access to prevention services and early diagnosis are recommended.

HIV/AIDS in 3 generations: case series.

BACKGROUND: The HIV pandemic is one of the greatest challenges facing humanity, and generations may be wiped out if effective prevention, treatment, and care are not in place. CASE REPORTS: A total of 3 families are presented. In the first 2, the children represented the third generation in their families to be infected with HIV and probably had mother-to-child transmission of the disease. The children in the third family were HIV negative. The mothers and grandmothers in all the families were infected with HIV. Risky sexual behavior involving multiple sexual partnering was recorded among them, some of whom had died from AIDS-related illness. This has serious implications in the care of the infected and affected children as they had been made vulnerable by their circumstances. CONCLUSION: HIV/AIDS has been around long enough now to cross generations as shown in the reported cases, which resulted in serious health and socioeconomic effects in the affected families.

Infant-feeding pattern of HIV-positive women in a prevention of mother-to-child transmission (PMTCT) programme.

OBJECTIVES: To evaluate the infant-feeding choices, practices and possible determinants among HIV-positive women enrolled in a prevention of mother-to-child transmission programme in Ibadan, Nigeria. METHODS: A cross-sectional survey involving HIV-positive women who had received infant-feeding counselling prior to delivery. A structured questionnaire was administered at < or = 72 hrs and not > or = 6 weeks of delivery and was complemented with an in-depth interview. RESULTS: A total of 241 women were studied. The choice of infant feeding was formula for 223 (93.5%) and in actual practice, 9 (3.7%) mothers admitted mixed feeding. There was no statistical significant difference between the feeding pattern and the socio-demographic characteristics. The major factor influencing the choice of infant feeding was "The desire to reduce the risk of transmission" which was recorded among 204 (84.6%) of the women. Greatest support in maintaining infant-feeding option was the spouse (36.1%). From the in-depth interview of 23 non-breastfeeding (infant formula) mothers, the major challenge faced was stigmatisation. CONCLUSION: Despite the premium placed on breastfeeding in this locality, with infant-feeding counselling, most HIV-positive women chose and practiced formula feeding. It is necessary to address how best HIV-positive mothers could handle or overcome criticisms and stigmatisation by others.

Comparison of socio-demographic and clinical characteristics of orphans and non-orphans among HIV-positive children in Ibadan, Nigeria.

OBJECTIVES: This study was carried out to determine the prevalence of HIV-positive orphans and to compare their socio-demographic and clinical characteristics with HIV-positive non-orphans. METHODS: A survey was conducted among patients attending the infectious disease clinic of the Department of Paediatrics, University College Hospital, Ibadan, Nigeria between July 2005 and November 2006. Information obtained included demographic data, orphan status, HIV/AIDS status of parents, current caregiver, school enrolment, and clinical parameters at presentation. RESULTS: Of the 110 children studied (mean age 43.5 months, SD 41.7 months), 58 (52.7%) were male and 74 (67.9%) presented with severe clinical disease, while 68.1% were malnourished. There were 40 orphans, giving a prevalence of 36.4%. Of this number, 13 (32.5%) were paternal orphans, 20 (50%) were maternal orphans, and seven (17.5%) were double orphans. Thirty-five (87.5%) were cared for within the family and none were in institutional care. Compared to non-orphans, orphans tended to be older at presentation (p=0.02). There were no significant differences in school enrolment, clinical stage of the disease, CD4 counts, or mean weight-for-age, weight-for-height, and height-for-age Z-scores at presentation between the two groups. CONCLUSION: It appears that the extended family system is currently coping with the orphan situation. There is need for provision of social and economic support to caregivers of children orphaned by AIDS before the family system is overwhelmed.

Etiologic agents and outcome determinants of community-acquired pneumonia in urban children: a hospital-based study.

Etiologic clues and prognostic indicators of community-acquired pneumonia (CAP) were sought in a 30-month study of under-5 admissions for acute lower respiratory infections (ALRIs). Investigative tools included blood culture, hemogram, immunofluorescence and serology. Associations of variables were tested using standard statistical tools. Of 419 ALRI, 323 (77%) had pneumonia, 234 (72.4%) bronchopneumonia, 66 (20.4%) lobar pneumonia and 23 (7.1%) both. More than 70% had poor parental socioeconomic parameters, 56.8% were overtly malnourished, 37.8% lived in overcrowded homes and 16.7% had been potentially exposed to wood smoke. Despite preconsultation antimicrobial use in 35.6%, 59 (28.8%) of 205 blood cultures proved positive; Staphylococcus aureus accounted for 22 (37.3%), Klebsiella species nine (15.3%) and Streptococcus pneumoniae three (5.1%). Ninety-two viruses were identified in 61 (50%) of 122 analyses. Respiratory syncytial virus (RSV) accounted for 28 (30.4%), parainfluenza virus type 3 (PIV-3) for 18 (19.5%) and influenza type-A (flu-A) 16 (17.3%). Twenty (16.4%) had > or = 2 viruses, while 40% of bacteremic cases with positive viral identification(s) had PIV-3. Pathogen detection was neither associated with hematologic parameters nor the final respiratory diagnosis. There were 35 (10.8%) deaths. Mortality was associated with maternal illiteracy (p = 0.045), wood smoke exposure (p = 0.006), preconsultation antimicrobial use (p = 0.04), malnutrition (p = 0.0003), bacteremia (p = 0.006) and polymorphonuclear leucocytosis (p = 0.023/0.013). RSV, PIV-3, flu-A, S. aureus and Klebsiella species constitute the major pathogens of pediatric CAP in urban Nigeria, while malnutrition, wood smoke exposure and bacteremia are strong risk factors of mortality. The poor prognostic import of antimicrobial abuse, vis-a-vis the apparent selection of necrotizing pathogens, are compelling indications for a reappraisal of current regional antimicrobial policies and exploring newer frontiers of disease control, including vaccine prevention.

Concurrent bacteraemia and malaria in febrile Nigerian infants.

In the tropics, febrile illnesses are often presumed to be due to malaria, because of its endemicity, and treatment can lead to delay in diagnosis or failure to detect severe infections such as bacteraemia. This study sought to determine the prevalence of bacteraemia and malaria parasitaemia in febrile post-neonatal infants (age 1-12 months) at the University College Hospital, Ibadan, Nigeria, and the bacterial aetiological agents of bacteraemia in the infants. Therefore, 102 infants aged 1-12 months who presented with fever with a negative history of antimicrobial use in the week prior to presentation were evaluated and had blood cultures done for the detection of aerobic organisms by standard methods and blood films for malaria parasites. Bacteraemia was found in 38.2% of the infants, malaria parasitaemia was found in 46.1%. The most common organisms isolated were Escherichia coli (35.9%), Staphylococcus aureus (33.3%) and Klebsiella spp. (10.3%). Febrile children should be investigated for the presence of bacterial infection even if the blood film for malaria parasites is positive. Where laboratory facilities are not available, consideration should be given to the use of both anti-malarial therapy and empiric antibiotic therapy in the management of febrile infants, depending on the clinician's judgement.

Predictors of bacteraemia among febrile infants in Ibadan, Nigeria.

Fever is a common complaint in infancy, and bacteraemia is one of the more serious causes of such fever. However, there exists scanty data on risk of bacteraemia among febrile infants of developing countries and what clinical predictors, if any, could identify those febrile infants with bacteraemia. To address this issue, 102 infants aged 1-12 month(s) attending the Children's Emergency Ward of University College Hospital, Ibadan, Nigeria, with rectal temperatures of > or = 38 degrees C and with a negative history of antimicrobial use for at least one week prior to presentation, were studied to identify clinical predictors of bacteraemia. Infants, meeting the eligibility criteria of the study, underwent a full clinical evaluation and had blood cultures done for aerobic organisms by standard methods. Over 38% of the infants had bacteraemia. Escherichia coli (35.9%), Staphylococcus aureus (33.3%), and Klebsiella spp. (10.3%) of positive cultures were commonly isolated. Three variables, age of < or = 6 months, restlessness, and a white cell count of >15,000/mm3, were significant independent predictors of bacteraemia. Each of these variables was associated with a 3-6-fold increase in risk of bacteraemia (age of < or = 6 months: odds ratio 3.2, p = 0.017; restlessness: odds ratio 6.3, p = 0.019; and white cell count of >15,000/mm3: odds ratio 5.4, p = 0.024). The variables, in combination, correctly classified 70% of the infants into 'bacteraemia' or 'no bacteraemia'. It is concluded that; in the setting of the study, about 4 in 10 febrile infants would have a positive blood culture for aerobic organisms and that age of < or = 6 months, restlessness, and a white cell count of > or = 15,000/mm3 are associated with a significantly increased risk of bacteraemia. Clinicians practising in such a setting need to be aware of the increased risk of bacteraemia in infants with these clinical features.