Joanne Potterton

The effect of a basic home stimulation programme on the development of young children infected with HIV

Aims  The human immunodeficiency virus (HIV) potentially causes a significant encephalopathy and resultant developmental delay in infected children. The aim of this study was to determine whether a home‐based intervention programme could have an impact on the neurodevelopmental status of children infected with HIV.

The extent of delay of language, motor, and cognitive development in HIV-positive infants.

Purpose: The aim of this study was to determine the extent of delay in acquisition of language, cognitive, and motor skills of children infected with human immunodeficiency virus (HIV). Methods: Forty HIV-positive, antiretrovirus-naive children aged 18 to 30 months attending the Harriet Shezi Pediatric HIV clinic at Chris Hani Baragwanath Hospital, Johannesburg, South Africa, were assessed using the Bayley Scales of Infant Development II (BSID II). The facet scoring section was used to descriptively analyze cognitive, language, and motor development. The Mental and Psychomotor Developmental Indices of the BSID II were used to determine the extent of mental and motor delays. Results: Mean cognitive development was 7.63 months delayed (P < 0.001) and mean motor development was 9.65 months delayed (P < 0.001), with 97.5% of the sample functioning below expected motor and cognitive age. Eighty-five percent of the sample demonstrated gross motor delay, which was the most adversely affected skill. Language was descriptively analyzed, revealing global language delay in 82.5% of the children. Gross motor delay may be attributed to decreased strength or to HIV encephalopathy. Conclusion: Cognitive delay may be because of disease progression and structural damage to the brain, and language delay may be attributed to neurological impairment, cognitive delay, or environmental deprivation. Based on these results, infants and children should be referred to physiotherapy to address the gross motor deficits noted.

The neurodevelopment of HIV-infected infants on HAART compared to HIV-exposed but uninfected infants

The aim of this study was to compare the neurodevelopment of HIV-infected (HI) infants in combination with antiretroviral therapy also known as HAART (highly active antiretroviral therapy) to HIV-exposed uninfected (HEU) infants. Twenty-seven HIV infected and 29 HEU infants under the age of one year attending the Empilweni Clinic at Rahima Moosa Mother and Child Hospital were studied. HI infants were assessed prior to initiating HAART and then for six months whilst on HAART. Neurodevelopment was assessed using the Bayley Scales of Infant and Toddler Development, 3rd ed (Bayley III). The HI infants scored significantly lower when compared to HEU infants for motor and language development at baseline, three months and six months follow up. No significant improvement in language (p = 0.46) and motor function (p = 0.91) occurred over time; however, developmental scores did not decrease. Cognitive development in the HI group was significantly lower when compared to the HEU group at visit one (p = 0.003). By six months follow-up, there were no significant differences between the two groups for cognitive development (p = 0.18). This study suggests that HIV-positive infants are delayed when compared to HEU infants. HAART may help to prevent further delay; however, it does not reverse the neurological damage already present. There is a need for therapists to be involved in pediatric HIV clinical services in order to provide early developmental screening as well as rehabilitative services to those children in need.

Neurodevelopmental delay in children infected with human immunodeficiency virus in Soweto, South Africa

HIV in children is a serious and growing problem in sub-Saharan Africa. At present very little is known about the neurological complications of human immunodeficiency virus (HIV)-infected children in South Africa. The aim of this study was to determine the extent and prevalence of neurodevelopmental delay in a group of HIV-positive children in Soweto, South Africa, as well as to determine what factors were predictive of neurodevelopmental delay. One hundred and twenty-two consecutive HIV-positive children under 2.5 years of age were assessed using the Bayley Scales of Infant Development II. Ethical approval and informed consent were obtained prior to testing. The children assessed in this study were extremely delayed in both motor and cognitive development. Seventy-two per cent of the children had severe motor delay and 52% had severe cognitive delay. The mean age of the children was 18.5 months (±8.1). The mean CD4 count was 14.4% (±8.8) and only 16% of the children were receiving highly active antiretroviral therapy (HAART). Weight, height and head circumference Z‐scores were also very low in this group of children, with both stunting and wasting being extremely common. Neurodevelopmental delay was very common in this group of children. Motor development was affected more severely than cognitive development. Weight-for-age, age and whether the child was on HAART were the most important factors in predicting cognitive and motor development. Poverty and poor socioeconomic status of families of HIV-infected children may well be additional developmental risk factors.

Socio-economic and clinical factors predictive of paediatric quality of life post burn

Burns represent the second most common cause of non-intentional death in children under the age of five. Burns are amongst the most traumatic injuries and may impose significant psychological, educational, social and future occupational limitations to the young child. This cross-sectional study aimed to determine the socio-economic and clinical factors which predict quality of life in children with burn in a burns unit in South Africa. The Paediatric Quality of Life Inventory (PedsQL) and the Household Economic and Social Status Index (HESSI) questionnaires were administered to children and their caregivers one week and three months post discharge from the Johnson and Johnson Paediatric Burns Unit, Chris Hani Baragwanath Hospital, Soweto. The improvement in the PedsQL scores suggests that the quality of life for children three months after discharge is good despite being burnt. The severity of the burn was found to be a significant predictor of quality of life (p=0.00). Poor socio-economic status was clearly evident in demographic data of the subjects. The findings from this study are particularly important in identifying areas for further research that would be beneficial to developing countries. Furthermore, the results are important in the move towards more holistic care for paediatric burn survivors.

Developmental delay in HIV-exposed infants in Harare, Zimbabwe

The aim of this cross-sectional study was to determine the difference in development (cognition; receptive and expressive language; and fine and gross motor) of human immunodeficiency virus (HIV)-exposed infected (HEI) infants with the development of HIV-exposed but uninfected (HEU) infants using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III). Sixty infants were enrolled in the study; 32 (53.33%) HEU infants and 28 (46.67%) HEI infants. The two groups were well-matched for infant demographics, anthropometry at birth and maternal demographics. Statistically significant differences were found in anthropometry and development between the HEI and HEU groups. The HEI infants had malnutrition, were stunted and had smaller head circumferences than HEU infants. The BSID-III showed that the mean developmental delay for the HEI group was approximately two months below their mean chronological age for all scales (cognitive; receptive and expressive communication; and fine and gross motor age). The HEI group showed that 64.29% had cognitive delay, 60.71% had language delay and 53.57% had motor delay, all of which were significantly different from the development of the HEU group for all domains (p < 0.001). In addition to using the BSID-III, the majority of mothers were able to correctly indicate whether their child was developing at the same or at a slower rate of development than children of the same age. This study demonstrates that infants who are HIV-exposed and infected are at risk of developmental delay.

Neurodevelopment and growth of institutionalized children with vertically transmitted human immunodeficiency virus

Human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) in sub-Saharan Africa has resulted in millions of children being infected with the virus and/or orphaned as a consequence of the virus. This is compounded by the fact that this area also has a high incidence of poverty, limited basic resources and malnutrition. Because HIV is both neurotrophic and lymphotrophic, infected children are at risk of developmental delays and growth impairments. Limited height-for-age (stunting) is a commonly reported finding. The objective of this study was to compare the neurodevelopment and anthropometric measurements of vertically infected HIV children not on antiretroviral treatment and HIV-uninfected children, as well as changes within the groups over 6–8 months. A comparative longitudinal study was conducted of 16 HIV-infected and 24 HIV-uninfected children between the ages of 16 and 42 months. The study sample was derived from two institutions in Gauteng, South Africa. Bayley Scales of Infant Development II were used to evaluate the childrens mental and motor development. Growth was assessed using mean Z-scores for weight-for-age, height-for-age, weight-for-height and head circumference-for-age. Evaluations were carried out at two time-points, 6–8 months apart. The results showed that HIV-infected children scored significantly lower than HIV-uninfected children at both time-points in neurodevelopment (mental developmental index p < 0.02 and p < 0.00; psychomotor developmental index p < 0.00 and p < 0.00) and also in anthropometric measurements (weight p < 0.00 and p < 0.01; height p < 0.00 and p < 0.00; head circumference p < 0.00 and p < 0.07). It is concluded that HIV affects the neurodevelopment (both mental and motor) and growth of HIV-infected children, particularly height-for-age.

Paediatric HIV encephalopathy in sub-Saharan Africa

Abstract Background: HIV/AIDS continues to be one of the greatest health challenges which sub-Saharan Africa faces. HIV is known to invade the central nervous system at the time of infection, and causes widespread damage. In children, this leads to a well-researched condition known as HIV encephalopathy, which affects all areas of neurodevelopment. Objectives: To discuss HIV encephalopathy in sub-Saharan Africa, and highlight the importance of early detection and intervention. Major findings: The effects of timely initiation of antiretroviral therapy on alleviating the impact of encephalopathy have been well described. Neurodevelopmental delay is a stage four disease indicator according to the World Health Organization (WHO), and therefore is a criterion for initiation of highly active antiretroviral therapy (HAART). HAART is often only administered according to the virologic and immunologic status of a child, as standardized neurodevelopmental assessment tools are not widely available in clinics in developing countries. When HAART initiation is dependent on immunologic status, it is often too late to prevent encephalopathy. To date, the only means of prevention of this condition is early initiation of HAART. Stringent guidelines for the commencement of this therapy have had to be followed due to a shortage of and lack of access to antiretrovirals, leading to late initiation of HAART, and widespread central nervous system encephalopathy. Conclusion: Early detection of encephalopathy is vital, so that children may commence treatment, and be referred for assessments in all facets of development in order to initiate intervention.

The development of a screening tool to evaluate gross motor function in HIV-infected infants

Neurodevelopmental delay or HIV encephalopathy is a stage four disease indicator for paediatric HIV/AIDS according to the World Health Organisation (WHO), and may be used as a criterion for initiation of highly active antiretroviral therapy (HAART). To date, the only means of prevention of this condition is early initiation of HAART. Studies which have been carried out in South African clinics have revealed the high prevalence of this condition. In developing countries, commencement of HAART is based on declining virologic and immunologic status, as standardised neurodevelopmental assessment tools are not widely available. A standardised developmental screening tool which is suitable for use in a developing country is therefore necessary in order to screen for neurodevelopmental delay to allow for further assessment and referral to rehabilitation services, as well as providing an additional assessment criterion for initiation of HAART. The infant gross motor screening test (IGMST) was developed for this purpose. The standardisation sample of the IGMST consisted of 112 HIV-infected infants between six and 18 months of age. Item selection for the IGMST was based on the Gross Motor scale of the Bayley Scales of Infant Development (BSID)-III. Content validity was assessed by a panel of experts using a nominal group technique (NGT; agreement >80%). Concurrent validity (n=60) of the IGMST was carried out against the BSID-III, and agreement was excellent (K=0.85). The diagnostic properties of the IGMST were evaluated and revealed: sensitivity 97.4%, specificity 85.7%, positive predictive value (PPV) 92.7%, and negative predictive value (NPV) 94.7%. Reliability testing (n=30) revealed inter-rater reliability as: r=1, test-retest reliability: r=0.98 and intra-rater reliability: r=0.98. The results indicate that the statistical properties of the IGMST are excellent, and the tool is suitable for use within the paediatric HIV setting.

Developmental status of preschool children receiving cART: a descriptive cohort study

BACKGROUND HIV is known to cause neurodevelopmental problems in infants and young children. The impact of HIV on the development of preschool-age children has been less well described. METHOD The study was conducted at an urban paediatric HIV clinic in Johannesburg, South Africa. A sample of convenience was used. Sixty-eight medically stable children between the ages of 3 and 5 years were assessed with the Griffiths Scales of Mental Development. Children were excluded from the study if they had severe HIV encephalopathy, which made it impossible for them to participate in the items on the Griffiths Scales of Mental Development. RESULTS The children had started combination antiretroviral treatment (cART) at a mean age of 8.1 months. The majority of the children were virologically suppressed and did not present with wasting or stunting. Severe overall developmental delay (z-scores < -2SD) was detected in 55.88% of children. Developmental facets related to speech, cognition and perception were the most severely affected. Personal-social development was the least affected with only 13.4% of the children demonstrating severe delay. CONCLUSION Despite having early access to cART, children infected with HIV are still at risk for severe developmental delay across a number of facets. Very early initiation of cART may help alleviate this problem. All preschool children infected with HIV should have routine developmental screening.