Management of community acquired pneumonia (CAP) in children: Clinical practice guidelines by the Paediatric Association of Nigeria (PAN

The Paediatric Association of Nigeria first published management guideline for community-acquired pneumonia in 2015 and covered available evidence at that time. This update represents a review of available recent evidence statements regarding the management of pneumonia in children, while at the same time incorporating relevant materials from the first edition of the guideline. The guideline is developed to assist clinicians in the care of children with CAP. The recommendations provided in this guideline may not be the only approach to management, since there are considerable variations among children in the clinical course of CAP.The goal of this guideline is to reduce morbidity and mortality rate of CAP in children by providing recommendations that may be relevant in assisting clinicians to make timely diagnosis and institute appropriate antibiotic therapy of children with CAP. Summarized below are recommendations made in the new 2021 CAP guideline. As part of the recommendations, the quality of the evidence is provided and the grade of the recommendation indicated.The details of the background, methods and evidence summaries that support each of these recommendations can be found in the full text of the guideline.

Impact of COVID-19 pandemic on immunization services in Nigeria; A preliminary report by Paediatric Association of Nigeria (PAN)

Background: Since the onset of the Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic also known as Coronavirus disease 2019 (COVID-19) beginning in Wuhan, China in December 2019 and spreading to Nigeria in February 2020 (as well as the rest of the world), there have been enormous resultant impact on health, social, emotional and economic aspects lives and services. The disease as well as its mitigation measures have negatively affected other aspects of lives and health services. This paper aims to assess the preliminary effects on immunization services, blow the whistle and suggest measures to limit these effects. Methods: Data was obtained by interviews and use of a structured proforma from Immunization Field Experts/Consultants working with national and international agencies in four states, heads of immunization units, officers in charge of immunization centres and facility immunization records from seven sites across Nigeria. Results: There were disrupted immunization services with total absence of outreach services and campaigns, limited fixed sessions, disease outbreaks, general drop in number of immunized children. These were thought to be due to the lockdown effects, fears, rumours and panic among others. Outright routine vaccines amongst rejections were also reported. Conclusion: Reports suggest that the pandemic and its mitigation measures are affecting immunization services in terms of demand/ access (physical and economic), services and logistics with overall drop in coverage and rise in dropout rates. The effects are still unfolding. It does not appear that health facilities are monitoring and interrogating their data with a view to making specific response action plans. All stakeholders in immunization (Government, non- governmental and professional organizations, the media, traditional / religious institutions) should work to flood the mainstream / social media with positive messages on immunization; monitor immunization progress by ongoing data collection, collation, analysis, interpretation and action; actively counter rumours and anti- vaccine messages and plan for post COVID 19 intensification/ catch- up

PREVALENCE OF HEAD LICE INFESTATION IN PRIMARY SCHOOL CHILDREN IN PORT HARCOURT.

BACKGROUND: Head lice infestation affects mainly school-aged children and prevalence varies from region to region. Head lice infestation is of public health concern and screening is integrated into the School Health Programme. OBJECTIVE: To determine the prevalence of head lice infestation in primary school-aged children in Port Harcourt, Nigeria. DESIGN: Cross-sectional descriptive study. SUBJECTS: A stratified multi-staged sampling technique was used to recruit pupils between six and 12 years of age, from thirteen primary schools located in three School Districts in the area. The heads of the pupils were inspected for head lice and nits with the aid of a battery operated Robi lice comb, magnifying glass and a torch as light source. RESULTS: A total of 1350 pupils were studied, 743 (55%) females and 607 (45%) males giving a female to male ratio of 1.2:1. Ten (0.7%) of the pupils had head lice infestation while five (0.4%) had evidence of past head lice infestation. The number of infested pupils among the younger age group (six to nine years) was seven (0.8%) and is higher, though not statistically significant, than that in the older age group (ten to twelve years) which was three (0.6%) (p = 0.453). No male was found to be infested while ten (1.3%) females were infested and the observed gender difference was statistically significant (p = 0.002). CONCLUSION: Head lice infestation still exists in Primary School children in Nigeria, therefore, screening for head lice infestation should still remain a part of the School Health Programme.

Knowledge and attitudes of parents toward children with epilepsy.

INTRODUCTION: The attitude towards people with epilepsy is influenced by the level of their knowledge about the condition. Parents usually do not accept the diagnosis of epilepsy in their children easily. This study was to assess 280 parents' knowledge and their attitude toward children suffering from epilepsy by answering a questionnaire. AIM: To evaluate the knowledge and attitudes of parents toward children with epilepsy. MATERIALS: This was a prospective study in a tertiary hospital. All parents who had children suffering from epilepsy seen from April 1st 2009 to March 31st 2010 were recruited. Questionnaires were administered to all the parents who attended the neurology clinic with their children diagnosed of epilepsy. RESULTS: A total of 914 neurological patients were seen and treated during the study period. Of these, 280 parents whose children suffered from epilepsy participated in the study. Almost all, 267 (95.36%) parents had heard about epilepsy prior to presentation in the clinic. Some parents thought that epilepsy was contagious and linked with evil spirit/demonic attack. A few of them rejected the word epilepsy and did not think that an epileptic child could achieve much in life. The knowledge about the clinical characteristics and initial procedures to attend a person during a seizure were unscientific. CONCLUSIONS: We concluded that more than 90% of parents and caregivers know about epileptic seizures. However, there is a need to disseminate more information to the public about its causes, clinical manifestation, approach to managing a convulsing child, and its outcome. In addition, periodic medical campaigns aimed at educating the public about epilepsy through the media could go a long way in reducing the morbidity and mortality associated with this disorder.

Anxiety Disorder amongst Secondary School Children in an Urban City in Nigeria.

Anxiety is a source of concern to the clinicians as it is co morbid with other mental disorders, particularly depression and learning disabilities, and it causes low self-esteem. The aim of this research was to evaluate the prevalence of anxiety disorder amongst secondary school children in Port Harcourt. A two-staged stratified sampling method was used to select the schools. Structured questionnaire based on Vanderbilt ADHD Diagnostic Teacher Rating Scale for anxiety and depression symptoms was used in evaluating the students. The questionnaires administered to the students were filled with the assistance of the researchers and the classroom teachers. Direct verbal interview was conducted for those noted to have symptoms of any of the various types of anxiety disorders and fears. Out of 885 students, 91 met the criteria for the diagnosis of anxiety/ depression disorder; prevalence was 10.28%, age range was 9-18 years. There were 37 males and 54 females giving a male: female ratio of 0.69:1. Majority 52 (57.14%) of the children lived with their parents, 28 (30.77%) of them lived with family relations and 11 (12.09%) of them were working as house helps to other families. The reasons given for being anxious were poor self image, fear of death, repeated physical and sexual abuses by their care givers and other adults. Learning disability was the major associated co morbid disorder (18.68%). Generalized anxiety was the most common type of anxiety disorder identified (32.97%). Anxiety disorders are debilitating chronic conditions. When it affects school aged children it contributes significantly to poor academic performance.

Growth pattern of exclusively breastfed infants in the first six months of life: a study of babies delivered at the University of Port Harcourt Teaching Hospital, Rivers State, Nigeria.

BACKGROUND: Some authors demonstrate that exclusively breastfed infants have growth patterns comparable with the NCHS standards while others conclude that exclusively breastfed infants grow slower. These conflicting results informed the need for this study to aid the paediatricians and health workers to justify or condemn the recommendation of exclusive breastfeeding for six months. This was a prospective longitudinal study carried out to determine the growth pattern of exclusively breastfed infants in the first 6 months of life and compare them with the International, National Centre for Health Statistics (NCHS/WHO) reference and the Local, Janes' Elite Standards. METHOD: Using weight, length and occipito-frontal circumference as indices, 530 infants were recruited consecutively by convenience sampling over 17 months. Measurements were taken at birth, 2 weeks, 6 weeks, 2 months and subsequently monthly until the end of the 6th month. RESULTS: The exclusively breastfed infants doubled their birth weights at 3 months. The mean weight, OFC and length gains were maximal at 2 months, 2 weeks and 2 months respectively The growth of exclusively breastfed infants compared favourably with the NCHS/WHO reference group and also compared favourably with the Janes' 'Elite' reference group. CONCLUSION: It is concluded that the growth in weight, length and OFC of exclusively breastfed infants appears adequate for the first 6 months of life.

Seroprevalence of hepatitis B surface antigenaemia in children in a tertiary health institution in the Niger Delta of Nigeria.

BACKGROUND: There is paucity of data on the seroprevalence of HBV infection in children living in urban areas of the Niger Delta of Nigeria. The aim of this study is to determine the seroprevalence of hepatitis B surface antigenaemia among children presenting to the University of Port Harcourt Teaching Hospital (UPTH), to determine the trend in the seroprevalence of HBsAg over a five-year period and to correlate serological findings to clinical features. METHODS: Serum samples from 251 consecutively recruited children in UPTH aged =16 years were tested for Hepatitis B surface antigen using Clinotech HBsAg kits and confirmed using the Trinity Biotec enzyme linked immunosorbent assay based HBsAg kits. Medical records of the children were also obtained. RESULTS: The overall prevalence of HBsAg among children tested was 12.4%. HBsAg prevalence was highest in the 11-15 years age group (24.5%) and the lowest in the 6-10 years age group (11.0%). There was a statistically significant difference in the prevalence of HB V positivity based on age groups (?2, = 8.47, p = 0.014). Prevalence rate was relatively higher among males (13.7%) compared to females (10.7%). There is a statistically significant trend in the decline of HBsAg prevalence 1999 to 2004 (?2, for trend = 11.38, p = 0.001). The predominant symptoms among children positive for HBsAg were hepatosplenomegaly (75%) and jaundice (64.5%). CONCLUSION: This study indicates a high prevalence of HBsAg among children presenting to a tertiary health facility in Port Harcourt.

Seroprevalence of Hepatitis B Surface Antigenaemia in Children in a Tertiary Health Institution in the Niger Delta of Nigeria

BACKGROUND: There is paucity of data on the seroprevalence of HBV infection in children living in urban areas of the Niger Delta of Nigeria. The aim of this study is to determine the seroprevalence of hepatitis B surface antigenaemia among children presenting to the University of Port Harcourt Teaching Hospital (UPTH), to determine the trend in the seroprevalence of HBsAg over a five-year period and to correlate serological findings to clinical features. METHODS: Serum samples from 251 consecutively recruited children in UPTH aged =16 years were tested for Hepatitis B surface antigen using Clinotech HBsAg kits and confirmed using the Trinity Biotec enzyme linked immunosorbent assay based HBsAg kits. Medical records of the children were also obtained. RESULTS: The overall prevalence of HBsAg among children tested was 12.4%. HBsAg prevalence was highest in the 11-15 years age group (24.5%) and the lowest in the 6-10 years age group (11.0%). There was a statistically significant difference in the prevalence of HB V positivity based on age groups (?2, = 8.47, p = 0.014). Prevalence rate was relatively higher among males (13.7%) compared to females (10.7%). There is a statistically significant trend in the decline of HBsAg prevalence 1999 to 2004 (?2, for trend = 11.38, p = 0.001). The predominant symptoms among children positive for HBsAg were hepatosplenomegaly (75%) and jaundice (64.5%). CONCLUSION: This study indicates a high prevalence of HBsAg among children presenting to a tertiary health facility in Port Harcourt

Barriers to timely initiation of breastfeeding among mothers of healthy full-term babies who deliver at the University of Port Harcourt Teaching Hospital.

OBJECTIVES: (I) To determine the barriers to timely initiation of breastfeeding in mothers who Hospital. (2). To determine if there is any statistical association between the time of initiation of breastfeeding and certain socio-demographic, obstetric, psychosocial and environmental factors in the mother-baby pairs. METHODOLOGICAL: A prospective, hospital-based study of 500 consecutive health mother-infant pairs delivered at UPTH (both vaginally and by Caesarian section). Information was obtained using a structured questionnaire, medical record review and direct observation. Early initiation, i.e. mothers who initiated breastfeeding within 30 minutes of delivery (in the case of the vaginally delivered (VD) mothers) or within 30 minutes of recovery of post-operative consciousness (in the case of those delivered by Caesarian section) were compared with those who initiated breastfeeding after 30 minutes (Late initiator) in the VD and C/S groups. The association between time of breastfeeding initiation and factors under consideration were determine using the chi-squared test. RESULTS: Approximately 34% of the VD mother initiated breastfeeding early while no mother with Caesarean section had early initiation of breastfeeding. The mean time of breastfeeding initiation was 3.35 -/+ 2.6 hours in mother who had vaginal delivery, 6.50 +/- 3.4 hours and 5.9 +/- 1.9 hours in those who had Caesarean section with general or spinal anaesthesia respectively. Among those with vaginal delivery, mothers younger than 25 years and of high socioeconomic class were found to practice early breastfeeding initiation. Delay in the time of repair of episiotomy and labour duration less than 12 hours were associated with early breastfeeding initiation. Early contact between baby and mother, help received on the delivery table and the presence of more than one delivery assistant also positively influenced breastfeeding initiation. Similarly, the presence of a breastfeeding-trained delivery assistant enhanced the mother' practice of early initiation of breastfeeding. Observation of routine labour ward practices such as cleaning of the newborn and weight/length measurement had negative impact on the practice of early initiation of breastfeeding. Early contact between the mother and her newborn on the delivery table with assistance to initate breastfeeding was the most important predictor of early breastfeeding initiation. Parity, attendance at the antenatal clinic, receipt of breastfeeding information and use of analgesics during labour did not show any statistical association with time of initiation of breastfeeding. CONCLUSION/RECOMMENDATION: There was a low prevalence of early initiation of breastfeeding in mothers delivered at the University of Port Harcourt Teaching Hospital. This low prevalence was due to delay in helping the newly delivered mother, especially those with Caesarean delivery. Routine labour ward practices interfere with the time of breastfeeding initiation. Routine labour ward and delivery table, specific assignment to the staff in the delivery/labour rooms help newly delivered mothers initiate breastfeeding early, and empowering the to request for babies are recommended.

Pattern of childhood deafness in an audiologic centre in Port Harcourt, Nigeria.

BACKGROUND: This study was conducted to determine the incidence of hearing impairment in children visiting a private audiology clinic on Port Harcourt, Nigeria, the type and degree of hearing impairment in these children, and to determine if there is any case for a community-based study on childhood hearing-impairment in the region. METHODS: This is a retrospective study of all persons up to the age of 15 years seen in an audiologic centre in Port Harcourt Nigeria over a 42 month period from January 2000 to June 2003. Demographic data were extracted from the medical records of each subject. Audiological evaluation was performed using standard Pure Tone Audiometry for subjects above 3 years and free-field audiometric techniques for those below 3 years. RESULTS: Sixty-two (48.9%) of the 127 persons 15 years and below who were examined showed evidence of hearing impairment. There were 29 males and 33 females (male:female ratio = 1:1.14). Age range was 2 to 15 years, mean = 8.3 +/- 4.6 years. Out of the 124 ears examined, 121 showed evidence of hearing impairment whilst 3 were normal. Bilateral hearing impairment was found in 59 (95.2%) of the subjects with hearing loss. Profound, severe, moderate and mild bilateral hearing loss were found in 42 (72%), 7 (11.9%), 6 (10.2%) and 4 (6.8%) subjects respectively. Ninety-seven (83.2%) of the 118 ears in subjects with bilateral hearing loss have, at least, severe hearing impairment. About 90% of the subjects with bilateral hearing loss had sensironeural hearing defect in at least one ear. CONCLUSION: Most of the cases of hearing impairment in our study were of profound/severe severity. Majority were of sensorineural type. There is the need for a community-based study to estimate the prevalence of hearing impairment in the study area.

Childhood epilepsy: knowledge and attitude of primary school teachers in Port Harcourt, Nigeria.

BACKGROUND: This study was conducted to determine the knowledge of primary school teachers in Port Harcourt metropolis of epilepsy, their knowledge of the management of an attack of epilepsy and the attitude of these teachers towards epilepsy in children. METHODS: This is a questionnaire-based, cross-sectional study of 118 school teachers from five randomly selected primary schools in Port Harcourt metropolis, Nigeria. RESULTS: Ten percent (12) of the 118 teachers were graded "Good", 45% (54) "Fair" and 43% (52) "Poor" in overall knowledge score. Sixty six teachers (56%) accept applying crude oil on the body as useful in stopping epileptic attacks in children. There was no significant association between overall knowledge score and sex, year of experience as a teacher and experience with a child with epilepsy. Only 10% of the teachers studied were classified as having overall good knowledge of epilepsy. Sixty nine teachers (58.5%) were graded as having good knowledge of cause of epilepsy. Only 38 (32%) disagree that the saliva drooled during an epileptic attack is contagious; one hundred (84.8%) and 65 (55.1%) agree that some childhood illnesses can cause epilepsy and that it runs in families respectively. Overall, 54 teachers (45.8%) had a cumulative score of negative attitude towards epilepsy. Eighty three teachers (73.3%) would want all children with epilepsy put in a special school whilst 57 (48%) agree that children with epilepsy should be withdrawn from schools. The longer the teacher's professional experience, the more the likelihood of positive attitude towards epilepsy but the association did not reach statistically significant level (p = 0.076). Attitude was not statistically associated with sex and educational qualification. CONCLUSIONS: The overall knowledge of primary school teachers in Port Harcourt metropolis of epilepsy and the first-aid management of an epileptic attack is poor. The attitude of these teachers towards epilepsy is negative. Education of the primary school teacher and general public on epilepsy is recommended.

Growth pattern of exclusively breastfed infants in the first six months of life: a study of babies delivered at the University of Port Harcourt Teaching Hospital, Rivers State, Nigeria.

BACKGROUND: Some authors demonstrate that exclusively breastfed infants have growth patterns comparable with the NCHS standards while others conclude that exclusively breastfed infants grow slower. These conflicting results informed the need for this study to aid the paediatricians and health workers to justify or condemn the recommendation of exclusive breastfeeding for six months. This was a prospective longitudinal study carried out to determine the growth pattern of exclusively breastfed infants in the first 6 months of life and compare them with the International, National Centre for Health Statistics (NCHS/WHO) reference and the Local, Janes' Elite Standards. METHODS: Using weight, length and occipito-frontal circumference as indices, 530 infants were recruited consecutively by convenience sampling over 17 months. Measurements were taken at birth, 2 weeks, 6 weeks, 2 months and subsequently monthly until the end of the 6th month. RESULTS: The exclusively breastfed infants doubled their birth weights at 3 months. The mean weight, OFC and length gains were maximal at 2 months, 2 weeks and 2 months respectively. The growth of exclusively breastfed infants compared favourably with the NCHS/WHO reference group and also compared favourably with the Janes' 'Elite' reference group. CONCLUSION: It is concluded that the growth in weight, length and OFC of exclusively breastfed infants appears adequate for the first 6 months of life.

The influence of pre- and post-partum factors on the time of contact between mother and her new-born after vaginal delivery.

BACKGROUND: The aim of this report is to determine the pre-partum and post-partum factors that may influence the time interval from vaginal delivery to first skin-to-skin contact between the mother and her newborn at the University of Port Harcourt Teaching Hospital. METHOD: A prospective study of 250 consecutive healthy mother-infant pairs. Information on pre- and post-partum factors was obtained from interview of mothers, direct observation and medical records. The proportion of mothers who made skin-to-skin contact with their babies within 30 minutes of delivery (early contact) was compared with those who did not (late contact) in the various pre- and post-partum groups. RESULTS: There was early skin-to-skin contact between mother and child in ninety-six (38.4%) of the 250 mother-infant pairs. Age of mother below 25 years, primiparity, labour less than 12 hours and late repair of episiotomy were associated with early skin-to-skin contact between mother and child. Early performance of routine cleaning and taking measurements of newborn was significantly associated with late skin-to-skin contact with mother. A significantly high proportion of mothers who were assisted to breastfeed had early contact with their babies compared with those who did not have any such assistance (48.8% vs. 17.1%). Ninety-six (39.7%) of the 242 mothers who received information on breastfeeding had early contact compared with none of the 8 mothers who did not have breastfeeding education. The mother's marital status and level of education did not show any statistically significant association with time of mother skin-to-skin contact with baby. CONCLUSION/RECOMMENDATION: Post-partum labour ward practices (cleaning and measurement of baby, assistance received by mother on breastfeeding and timing of repair of episiotomy) are the most important factors found to affect time of first contact between mother and child. It is recommended that immediate contact between newborn and mother should take precedence over hospital routines.

Survey of knowledge of HIV infection among senior secondary school 3 (SSS3) students in Port Harcourt.

BACKGROUND: The objective of this paper is to study the knowledge of the students on Human Immunodeficiency Virus and Acquired Immunodeficiency Deficiency Disease (HIV/AIDS) among third year senior secondary school (SSS3) students in Port Harcourt metropolis. METHOD: This was a cross-sectional survey involving 1800 SSS3 students from thirteen secondary schools in Port Harcourt metropolis, selected by a two-stage stratified sampling technique, using a self administered structured questionnaire. RESULTS: Thirty one percent, 14.4%, 9.1% and 8% of the students studied identified sexual intercourse, blood transfusion, mother to child (vertical) transmission and intravenous drug use, respectively, as modes of transmission of HIV infection. Only 7.1% identified all the listed four modes of transmission of HIV whilst 0.7% of the students identified all the listed preventive methods. The level of knowledge of the students on HIV did not significantly increase with age (p = 0.745). Students from Federal school demonstrated more knowledge than students from state and private schools. Similarly, students from all-male school had more knowledge than students from all-female and co-educational schools. Students from high social class demonstrated more knowledge than those from middle and low social class. CONCLUSION: It is concluded that the knowledge of the students on the transmission and prevention of HIV/AIDS is poor. There is need to intensify HIV/AIDS education programmes among adolescents.

Malaria parasite density and splenic status by ultrasonography in stable sickle-cell anaemia (HbSS) children.

BACKGROUND: To determine the relationship, if any, between malaria parasitaemia, parasite density and presence/size of the spleen, using abdominal ultrasonography in stable sickle cell anaemia subjects aged 6 to 15 years. METHODS: A prospective study of one hundred consecutive sickle cell anaemia (SCA) and 100 matched healthy HbAA controls aged 6 to 15 years was undertaken. The presence of malaria parasite, and parasite density were determined using thick blood film. Splenic status was determined by using abdominal ultrasound. None of the children was symptomatic for malaria. RESULTS: The prevalence of autosplenectomy and splenomegaly were 20% and 27% respectively in SCA subjects compared to 0% and 4% respectively in HbAA controls. Thirty percent and 34% of the SCA and controls respectively had malaria parasitaemia. In SCA subjects, the parasite density ranged from 33 to 4000 per microl with a mean of 1071.10 +/- 895.5 per microl. In HbAA controls, the parasite density ranged from 180 to 5150 per microl with a mean of 1759 +/- 1382.87 per microl. The difference in parasite density between SCA subjects and HbAA was significant p<0.05. The parasite densities were relatively higher among SCA with splenomegaly and normal spleen sizes compared to SCA subjects with autosplenectomy. CONCLUSIONS: The prevalence of malaria parasitaemia is lower in healthy SCA subjects than in HBAA controls. Sickle cell anaemia subjects have lower malaria parasite density. Autosplenectomy may be a positive adaptation in SCA subjects with effective innate immunity to malaria.