Improved Neonatal Mortality at a District Hospital in Aweil, South Sudan.

Neonatal deaths comprise a growing proportion of global under-five mortality. However, data from the highest-burden areas is sparse. This descriptive retrospective study analyses the outcomes of all infants exiting the Médecins sans Frontières-managed neonatal unit in Aweil Hospital, rural South Sudan from 2011 to 2014. A total of 4268 patients were treated over 4 years, with annual admissions increasing from 687 to 1494. Overall mortality was 13.5% (n = 576), declining from 18.7% to 11.1% (p for trend <0.001). Newborns weighing <2500 g were at significantly increased mortality risk compared with babies ≥2500 g (odds ratio = 2.27, 95% confidence interval = 1.9-2.71, p < 0.001). Leading causes of death included sepsis (49.7%), tetanus (15.8%), respiratory distress (12.8%) and asphyxia (9.2%). Tetanus had the highest case fatality rate (49.7%), followed by perinatal asphyxia (26.5%), respiratory distress (20.4%) and neonatal sepsis (10.5%). Despite increasing admissions, overall mortality declined, indicating that survival of these especially vulnerable infants can be improved even in a basic-level district hospital programme.

Routine Amoxicillin for Uncomplicated Severe Acute Malnutrition in Children.

BACKGROUND: High-quality evidence supporting a community-based treatment protocol for children with severe acute malnutrition, including routine antibiotic use at admission to a nutritional treatment program, remains limited. In view of the costs and consequences of emerging resistance associated with routine antibiotic use, more evidence is required to support this practice. METHODS: In a double-blind, placebo-controlled trial in Niger, we randomly assigned children who were 6 to 59 months of age and had uncomplicated severe acute malnutrition to receive amoxicillin or placebo for 7 days. The primary outcome was nutritional recovery at or before week 8. RESULTS: A total of 2412 children underwent randomization, and 2399 children were included in the analysis. Nutritional recovery occurred in 65.9% of children in the amoxicillin group (790 of 1199) and in 62.7% of children in the placebo group (752 of 1200). There was no significant difference in the likelihood of nutritional recovery (risk ratio for amoxicillin vs. placebo, 1.05; 95% confidence interval [CI], 0.99 to 1.12; P=0.10). In secondary analyses, amoxicillin decreased the risk of transfer to inpatient care by 14% (26.4% in the amoxicillin group vs. 30.7% in the placebo group; risk ratio, 0.86; 95% CI, 0.76 to 0.98; P=0.02). CONCLUSIONS: We found no benefit of routine antibiotic use with respect to nutritional recovery from uncomplicated severe acute malnutrition in Niger. In regions with adequate infrastructure for surveillance and management of complications, health care facilities could consider eliminating the routine use of antibiotics in protocols for the treatment of uncomplicated severe acute malnutrition. (Funded by Médecins sans Frontières Operational Center Paris; ClinicalTrials.gov number, NCT01613547.).

A Retrospective Analysis of Pediatric Cases Handled by the MSF Tele-Expertise System.

We conducted a retrospective analysis of all pediatric cases referred by Médecins Sans Frontières (MSF) field doctors via the MSF telemedicine system during a 4-year period from April 2010. A total of 467 pediatric cases were submitted, representing approximately 40% of all telemedicine cases. The median age of the patients was 4 years. The median response time (i.e., the interval between the case being submitted and the first response from a specialist) was 13 h (interquartile range 4-32 h). We selected a random sample of 12 pediatric cases in each of four age categories for detailed analysis by an experienced MSF pediatrician. In the 48 randomly selected cases, the mean rating for the quality of information provided by the referrer was 2.8 (on a scale from 1 = very poor to 5 = very good), and the mean rating for the appropriateness of the response was 3.3 (same scale). More than two-thirds of the responses were considered to be useful to the patient, and approximately three-quarters were considered to be useful to the medical team. The usefulness of the responses tended to be higher for the medical team than for the patient, and there was some evidence that usefulness to both groups was lower in newborns and adolescent patients. The telemedicine system allows the quality of the medical support given to medical teams in the field to be controlled objectively as there is a record of all cases and answers. Telemedicine has an important role in supporting the aims of medical humanitarian organizations such as MSF.

Infections in children admitted with complicated severe acute malnutrition in Niger.

BACKGROUND: Although malnutrition affects thousands of children throughout the Sahel each year and predisposes them to infections, there is little data on the etiology of infections in these populations. We present a clinical and biological characterization of infections in hospitalized children with complicated severe acute malnutrition (SAM) in Maradi, Niger. METHODS: Children with complicated SAM hospitalized in the intensive care unit of a therapeutic feeding center, with no antibiotics in the previous 7 days, were included. A clinical examination, blood, urine and stool cultures, and chest radiography were performed systematically on admission. RESULTS: Among the 311 children included in the study, gastroenteritis was the most frequent clinical diagnosis on admission, followed by respiratory tract infections and malaria. Blood or urine culture was positive in 17% and 16% of cases, respectively, and 36% had abnormal chest radiography. Enterobacteria were sensitive to most antibiotics, except amoxicillin and cotrimoxazole. Twenty-nine (9%) children died, most frequently from sepsis. Clinical signs were poor indicators of infection and initial diagnoses correlated poorly with biologically or radiography-confirmed diagnoses. CONCLUSIONS: These data confirm the high level of infections and poor correlation with clinical signs in children with complicated SAM, and provide antibiotic resistance profiles from an area with limited microbiological data. These results contribute unique data to the ongoing debate on the use and choice of broad-spectrum antibiotics as first-line treatment in children with complicated SAM and reinforce the call for an update of international guidelines on management of complicated SAM based on more recent data.

Antiretroviral therapy outcomes in resource-limited settings for HIV-infected children <5 years of age.

OBJECTIVE: We describe medium-term outcomes for young children receiving antiretroviral therapy (ART) in resource-limited countries. METHODS: Analyses were conducted on surveillance data for children <5 years of age receiving ART (initiated April 2002 to January 2008) in 48 HIV/AIDS treatment programs in Africa and Asia. Primary outcome measures were probability of remaining in care, probability of developing World Health Organization stage 4 clinical events, rate of switching to second-line ART, and drug toxicity, compared at 6, 12, 24, and 36 months of ART. RESULTS: Of 3936 children (90% in Africa) initiating ART, 9% were <12 months, 50% were 12 to 35 months, and 41% were 36 to 59 months of age. The median time of ART was 10.5 months. Probabilities of remaining in care after 12, 24, and 36 months of ART were 0.85, 0.80, and 0.75, respectively. Compared with children 36 to 59 months of age at ART initiation, probabilities of remaining in care were significantly lower for children <12 months of age. Overall, 55% and 69% of deaths and losses to follow-up occurred in the first 3 and 6 months of ART, respectively. Probabilities of developing stage 4 clinical events after 12, 24, and 36 months of ART were 0.03, 0.06, and 0.09, respectively. Only 33 subjects (0.8%) switched to second-line regimens, and 151 (3.8%) experienced severe drug toxicities. CONCLUSIONS: Large-scale ART for children <5 years of age in resource-limited settings is feasible, with encouraging clinical outcomes, but efforts should be increased to improve early HIV diagnosis and treatment.

Attitudes to HIV testing among carers of children admitted to Port Moresby General Hospital, Papua New Guinea.

AIM: To assess the acceptability of voluntary counselling and testing among the carers of children admitted to hospital in Papua New Guinea. METHODS: Forty semistructured interviews were carried out between February and April 2007. RESULTS: All the carers interviewed were women, mostly from Port Moresby. Virtually all of them attended primary school. About half of them attended secondary school but none completed it. Half of them knew an adult or child with HIV. Three quarters of the women interviewed would consent to having a child in their care tested for HIV, and over half of those who had never been tested would agree to be tested themselves. Correct answers to more than half the HIV knowledge questions posed were significantly related to agreement to an HIV test. CONCLUSIONS: This study supports the need for further evaluation of knowledge about HIV/AIDS and opportunities for health promotion in this group of women, particularly in view of the implication for voluntary counselling and testing and prevention of mother-to-child HIV transmission programmes in Papua New Guinea.