André Venter

Aerosol Inhalation From Spacers and Valved Holding Chambers Requires Few Tidal Breaths for Children

OBJECTIVE: The goal was to determine the number of breaths required to inhale salbutamol from different spacers/valved holding chambers (VHCs). METHODS: Breathing patterns were recorded for 2- to 7-year-old children inhaling placebo from 4 different spacers/VHCs and were simulated by a flow generator. Drug delivery with different numbers of tidal breaths and with a single maximal breath was compared. RESULTS: With tidal breathing, mean inhalation volumes were large, ranging from 384 mL to 445 mL. Mean values for drug delivery with an Aerochamber Plus (Trudell, London, Canada) were 40% (95% confidence interval [CI]: 34%–46%) and 41% (95% CI: 36%–47%) of the total dose with 2 and 9 tidal breaths, respectively. Mean drug delivery values with these breath numbers with a Funhaler (Visiomed, Perth, Australia) were 39% (95% CI: 34%–43%) and 38% (95% CI: 35%–42%), respectively. With a Volumatic (GlaxoSmithKline, Melbourne, Australia), mean drug delivery values with 2 and 9 tidal breaths were 37% (95% CI: 33%–41%) and 43% (95% CI: 40%–46%), respectively (P = .02); there was no significant difference in drug delivery with 3 versus 9 tidal breaths. With the modified soft drink bottle, drug delivery. Drug delivery was not improved with a single maximal breath with any device. CONCLUSION: For young children, tidal breaths through a spacer/VHC were much larger than expected. Two tidal breaths were adequate for small-volume VHCs and a 500-mL modified soft drink bottle, and 3 tidal breaths were adequate for the larger Volumatic VHC.

The effect of feeding four different formulae on stool weights in prolonged dehydrating infantile gastroenteritis.

Prolonged diarrhea following an acute episode of dehydrating gastroenteritis in infants is often treated by the empirical removal of both cows milk protein and lactose from the feed, as they both have been implicated in the prolongation of diarrhea. In order to assess the efficacy of this policy and to determine whether there are any advantages in using a lactose-free semi-elemental feed in this situation, infants with prolonged dehydrating gastroenteritis from a developing community in South Africa were studied. Male black children between the ages of 6 weeks and 2 years with prolonged dehydrating gastroenteritis (requiring intravenous fluids for longer than 72 h to maintain hydration) were randomly assigned to receive one of four feeds if the stool weight was greater than 30 g/kg body weight/24 h on the fourth day of admission. The four formula feeds were a partially modified cows milk formula; a lactose-free, casein-containing formula; a lactose-free, soy-protein-containing formula; and a lactose-free, whey-hydrolysate-containing formula. Stool weights were measured for the following 3 days. Seventy-two children were enrolled into the study. Stool weights were similar in the four groups at the start of the trial, and fell significantly over the trial period in those groups receiving the lactose-free feeds. Mean stool weight in the cows milk formula group did not change. Thus, it appears that the continued feeding of a cows milk-based lactose-containing formulae to infants with prolonged dehydrating gastroenteritis adversely affects their recovery.(ABSTRACT TRUNCATED AT 250 WORDS)

Child Neurology Services in Africa

The first African Child Neurology Association meeting identified key challenges that the continent faces to improve the health of children with neurology disorders. The capacity to diagnose common neurologic conditions and rare disorders is lacking. The burden of neurologic disease on the continent is not known, and this lack of knowledge limits the ability to lobby for better health care provision. Inability to practice in resource-limited settings has led to the migration of skilled professionals away from Africa. Referral systems from primary to tertiary are often unpredictable and chaotic. There is a lack of access to reliable supplies of basic neurology treatments such as antiepileptic drugs. Few countries have nationally accepted guidelines either for the management of epilepsy or status epilepticus. There is a great need to develop better training capacity across Africa in the recognition and management of neurologic conditions in children, from primary health care to the subspecialist level.

A randomized controlled study of the impact of dietary zinc supplementation in the management of children with protein-energy malnutrition in Lesotho. I: Mortality and morbidity.

Protein-energy malnutrition (PEM) remains one of the common causes of morbidity and mortality among children throughout the world. The supplementation of 10 mg elemental zinc, as zinc sulphate, was evaluated in the management of PEM in a randomized, controlled double-blind clinical trial in 300 children, aged 6-60 months (zinc, n = 150; control, n = 150) admitted to the Queen Elizabeth II Hospital, Maseru, Lesotho. Supplementation and follow-up were done for 3 months post-discharge from the hospital. Mortality during hospitalization was significantly lower in the zinc supplemented group (4.7 per cent), compared with 16.7 per cent in the control group. The prevalence of morbidity was significantly higher in the control group at 1, 2, and 3 months follow-up. In the zinc supplemented group 58 per cent of the children were above the 80th percentile of expected weight-for-age 3 months after discharge, compared with 27.6 per cent in the control group. Dietary zinc supplementation resulted in a significant reduction in diarrhoeal disease, respiratory morbidity, and episodes of clinical anaemia, skin infections, and fever as well as vomiting in children with PEM. These findings suggest that interventions to improve zinc intake in their management may be of benefit to Basotho children in Lesotho with PEM.

Children with epilepsy in Africa: recommendations from the International Child Neurology Association/African Child Neurology Association Workshop.

This article presents key findings from the International Child Neurology Association/African Child Neurology Association Workshop. The viability of international guidelines for the management of children with epilepsy should be reviewed within each African country, and adapted to comply with the regional capacity. Such recommendations can be used to lobby for resources. More training centers should be developed in Africa, so that specialists can be trained within Africa, in skills relevant to the continent, in collaboration with “out of Africa” visiting-specialists to develop the concept of “train the trainers.” At least 1 child neurology specialist per 100 000 of the population is required. Specific to Africa are the challenges from stigma, prejudice, and misconceptions. “Epilepsy teams,” inclusive of the traditional healers, would enable management of increased numbers of children, and challenge policy such that it is the right of the child with epilepsy to have reliable access to appropriate antiepileptic drugs, support, and health care equity between the rural and urban settings.

A randomized controlled study of the impact of dietary zinc supplementation in the management of children with protein-energy malnutrition in Lesotho. II: Special investigations.

Protein-energy malnutrition (PEM) remains one of the common causes of morbidity and mortality among children throughout the world. The supplementation of 10 mg elemental zinc, as zinc sulphate, was evaluated in the management of PEM in a randomized, controlled, double-blind clinical trial in 300 children, aged 6-60 months (zinc, n = 150; control, n = 150) admitted to the Queen Elizabeth II Hospital, Maseru, Lesotho. Supplementation and follow-up were done for 3 months post-discharge from the hospital. Both the supplemented and the control groups presented with biochemically determined zinc deficiency on presentation. Despite supplementation the treated group only began to show evidence of biochemical increase in serum zinc at 60 days post-discharge from hospital. This may represent the period of replacement of the total body zinc. Zinc deficiency was more severe in those children in the control group that died after admission to hospital than those that survived, suggesting that low serum levels in children with PEM are associated with a poor prognosis. Zinc did not emerge as a predicator of poor prognosis in the supplemented group as very few children died in this group. The supplemented group also made significant gains as far as albumin levels were concerned, which probably reflects rehabilitation of their malnutrition. The associated improvement in haematological parameters has not been described before and may be secondary to the decreased burden of disease in the supplemented group. These findings suggest that not only were significant benefits of zinc supplementation shown for morbidity in mortality of children in Lesotho with PEM, but these trends were also demonstrated on biochemical profiles.

Usefulness of parental response to questions about adherence to prescribed inhaled corticosteroids in young children

Background Adherence to prescribed inhaled medication is often low in young children. Poor adherence to medication may contribute to lack of symptom control. Doctors are not good at predicting the adherence rates of their patients, and parental report of adherence does not correlate with objective measures of adherence. The objective of this study was to investigate whether parental admission of non-adherence and reasons given for non-adherence correlated with objectively measured adherence. Methods Adherence to prescribed inhaled corticosteroid treatment was monitored electronically in 132 children aged 2–6 years who were participating in a randomised controlled trial comparing different inhaler devices. Follow-up was carried out every 3 months for a year. Parental answers to simple questions about adherence were compared to electronically measured adherence. Results Mean adherence ranged from zero to 100%. Intra-participant adherence varied throughout the year-long study period (mean variance for individual children between quarterly periods was 28.5%). Parents who reported missed doses, generally missed at least half of the prescribed doses. Parents who reported that not a single prescribed dose was missed, still missed 20% of doses on average. Adherence was particularly low when parents cited initiating their own trial off medication as a reason for missing doses. Conclusions By examining parental response to questions enquiring whether any doses were missed, healthcare providers can gain a modest degree of insight into their patients’ true adherence to prescribed medication. Adherence to prescribed asthma medication is extremely variable in young children. Trial registration number Data from this study were derived from a randomised controlled trial (ACTRN12608000294358).

Incentive device improves spacer technique but not clinical outcome in preschool children with asthma

Aim:  To investigate the influence of an incentive device, the Funhaler, on spacer technique and symptom control in young children with asthma and recurrent wheeze.

Intellectual Disability In Rural Black Children In The Bushbuckridge District Of South Africa

Abstract The aim of this project was to investigate the prevalence and aetiology of intellectual disability in rural black children in the Bushbuckridge district. Children (aged 2–9 years) were screened by local trained field-workers who interviewed the caregivers with a simple questionnaire. Children who screened positive were examined by a paediatrician. Altogether 4581 children were screened, 541 had a paediatric assessment, and 152 (3,3%) were found to have an intellectual disability (IQ ≤ 80). The mild to severe disability ratio was 4:1, and 52% of affected children with an IQ ≤ 70 had associated disorders. The aetiology of the disability was congenital in 25% of cases, acquired in 11% and undetermined in 64%. The affected male to female ratio was 3:2. These findings have implications for the provision of appropriate special education, as well as health preventive services.

A comparison between South African psychiatrists' and paediatricians' knowledge, attitudes and current practices regarding the management of children with Attention Deficit/Hyperactivity Disorder

The objective of this study was to determine the knowledge, attitudes and current practices of psychiatrists and paediatricians in South Africa regarding the management of children with Attention Deficit/Hyperactivity Disorder (ADHD), to determine if there are significant differences between them. Three hundred and forty psychiatrists and 517 paediatricians were identified from the address list of the Health Professionals Council of South Africa. Each specialist was sent a survey questionnaire with a letter explaining the objectives and aims of the research. The questionnaire explored four themes: demographic data; attitudes to caring for children with ADHD; management of these children and knowledge about the use of stimulants. One hundred and seventy three (57.6%) psychiatrists and 316 (61%) paediatricians responded. Of these 145 and 278 respectively were practising medicine, and 51.7% (75) of the psychiatrists and 61% (169) of the paediatricians indicated that they manage children with ADHD. The results of the survey indicate that paediatricians and psychiatrists have adequate knowledge of ADHD and its management. Possibly because of the organisation of their practices psychiatrists were not as concerned as paediatricians about the time spent on each patient, but they were less likely to refer to other professionals. On the other hand, paediatricians had more of an interdisciplinary approach to the management of children with ADHD, but found them time consuming, remuneration inadequate and had little time to prepare extensive reports or liase with other professionals or schools. Psychiatrists appear to function within a neuro-biological model and have more knowledge on neuro-pharmacology and physiology. Paediatricians have a greater educational and family awareness, possibly reflecting differences in training. Both groups use methylphenidate as the medication of choice and both have adequate knowledge of its benefits, side effects and contra-indications.