William A M Cutting

A preliminary evaluation of the cognitive and motor effects of pediatric HIV infection in Zairian children.

Fourteen asymptomatic HIV-infected Zairian children under 2 years of age displayed social and motor developmental deficits on the Denver Developmental Screening Test when compared with 20 HIV-negative cohorts born to HIV-infected mothers and 16 control children. In a second study, 11 infected children over 2 years of age had sequential motor and visual-spatial memory deficits on the Kaufman Assessment Battery for Children and motor development deficits on the Early Childhood Screening Profiles. HIV infection affects central nervous system structures mediating motor and spatial memory development, even in seemingly asymptomatic children. Furthermore, maternal HIV infection compromises the labor-intensive provision of care in the African milieu and undermines global cognitive development in even uninfected children.

Severe anaemia in pregnancy: a problem of primigravidae in rural Zaire

Haemoglobin levels were measured in 2950 pregnant women attending antenatal clinics in Kimpese, Bas Zaire. 72% were suffering from moderate anaemia (haemoglobin (Hb) 7-11 g/dl) and 3.7% from severe anaemia (Hb less than 7 g/dl) at their first visit, before receiving any haematinics or anti-malarial prophylaxis. Haemoglobin levels rose with both increasing parity (P less than 0.001) and age. Multiple regression analysis revealed that parity was significant but age was not. The fall in haemoglobin early in the second trimester was greatest in primigravidae and diminished with successive pregnancies until the fourth. One in 6 primigravidae approached labour with a haemoglobin level less than 7.7 g/dl. Thick blood smears were examined from 379 women who presented in the first and second trimester. 70% of primigravidae had malaria parasitaemia, compared with 13% of multigravidae (P less than 0.001). Early malaria prophylaxis in the first 2 pregnancies is an important primary health care objective if the contribution of malaria to the significant fall in haemoglobin in the second trimester is to be averted.

Genetic heterogeneity of HIV type 1 subtypes in Kimpese, rural Democratic Republic of Congo

A relatively low and stable seroprevalence of HIV-1 was previously reported among pregnant women attending for antenatal care between 1988 and 1993 in Kimpese, a rural town in the Democratic Republic of Congo (DRC, formerly Zaire). To characterize the HIV-1 subtypes circulating in this area, we have examined a 330-bp fragment of the p17 region of the gag gene of HIV-1 strains obtained from 70 patients (55 mothers, 15 children), of whom 61 were epidemiologically unlinked. Phylogenetic analyses revealed the existence of at least seven HIV-1 subtypes within the Kimpese region. Among the 61 epidemiologically unlinked patients, subtype A was predominant and found in 29 (47.5%) individuals. Other subtypes cocirculating in this rural part of DRC include subtypes C (1.6%), D (9.8%), F (3.2%), G (6.5%), H (21.3%), and J (4.9%). Sequences from four patients did not cluster with any of the currently documented HIV-1 subtypes, in analyses of fragments of both the gag (247 to 330 bp, 197 bp, and 310 bp) and env (340 bp) genes. Overall, comparisons of the gag(p17) gene regions revealed high pairwise divergences (mean, 19.9%; range, 1 to 46%). This level of gag(p17) gene variation in the DRC is considerably greater than previously appreciated. These results are relevant for the molecular epidemiology of HIV-1 in Africa and for the design of a future vaccine against HIV-1 in this region.

Typhoid fever ciprofloxacin and growth in young children.

Summary Typhoid fever remains a significant public health problem in Southern Asia, particularly with the emergence of multi-resistant strains of Salmonella typhi in the late 1980s. Use of ciprofloxacin in children, although discouraged, is increasing and we aimed to assess whether its use affects growth or the prevalence of joint symptomology. Children under 6 years of age diagnosed as typhoid fever on the basis of a positive Widal test were recruited in the outpatient department of a paediatric teaching hospital after treatment had been initiated. During 6 months follow-up, prevalences of arthritis/arthralgia and ponderal, linear and knemometric growth were recorded. Seventy-five children were recruited (mean age 32 months, mean weight-for-height Z-score—1.3, mean height-for-age Z-score 1.4) and 29 (39%) of them received ciprofloxacin. No significant adverse effects on ponderal, linear or knemometric growth, or on the incidence of arthritis/arthralgia were found to be associated with the use of ciprofloxacin. Knemometric and ponderal catch-up growth was demonstrable 30 days after diagnosis but linear growth was still declining 3 months after diagnosis with catch-up growth demonstrable only after 6 months. We conclude that ciprofloxacin is commonly used in typhoid fever and has no adverse effects on growth or joint symptomology.

BREAST FEEDING : THE BABY FRIENDLY INITIATIVE

Editor—We share Malik and Cutting’s enthusiasm for Unicef’s baby friendly initiative in the United Kingdom but were disappointed that they did not acknowledge the great progress made over the past year.1 It is pessimistic to state that hospitals have been slow to work with the initiative. In fact, almost all units are working towards baby friendly accreditation; 11 British maternity units have achieved the required standard and another 40 have a certificate of commitment. Although Malik and Cutting suggest that hospitals might be demoralised by unachievable targets (such as the 75% breastfeeding rate required for the global baby friendly award), we removed this requirement for the United Kingdom’s standard award in order to focus on the support and encouragement of best clinical practice. It is also unfair to suggest that the baby friendly initiative is confined to hospitals. On 15 May we launched best practice standards for community healthcare settings, with the support of the minister for public health. This is the first step in introducing the initiative into the community and provides a framework around which clinical accreditation will be developed. The United Kingdom will probably be unique in having a primary care baby friendly award. As with the existing awards, particular emphasis is placed on support for mothers to make informed decisions about feeding their babies. Malik and Cutting call for better coordination with existing groups that support mothers; in fact, all four national groups are fully involved with the baby friendly initiative. We were also puzzled by the statement that “government and NHS managers should recognise and encourage [the baby friendly initiative’s] development.” The Department of Health has worked in partnership with the initiative since its inception in the United Kingdom,2,3 while an increasing proportion of NHS managers see the initiative as a cost effective quality framework to achieve a high standard of care, which can be independently accredited. We agree that much more could be done to support mothers in their choice to breast feed. Nevertheless, the healthcare system has a crucial role; it was particularly pleasing to note that the 1995 infant feeding statistics4 documented progress on relevant hospital practices.5 We are optimistic that the progress of Unicef’s baby friendly initiative in the United Kingdom can strengthen this trend.

Breast feeding: the baby friendly initiative: Must adapt and develop to succeed

Breast feeding is unparalleled in providing an infant with ideal nourishment, protection from infections, and much more.1 2 Despite this, there is still a strong culture for bottle feeding in Britain.3 The global baby friendly hospital initiative, known in Britain as the baby friendly initiative, was launched jointly by UNICEF and the World Health Organisation in 1991. The objective was to reverse the negative impact that many maternity hospital practices have on establishing breast feeding. The “ten steps” (see box) are intended as a standard for good practice.4 The “Baby Friendly Initiative Golden Award” is given to hospitals that complete the 10 steps and achieve a 75% rate of breast feeding on discharge, and the British “Baby Friendly Initiative Award” to hospitals that achieve a 50% breast feeding rate on discharge. By December 1996 there were only three baby friendly hospitals in Britain and another 10 that had a certificate of commitment (for achieving steps 1, 7, and 10). #### The “ten steps” to successful breast feeding Step 1 . Have a written breast feeding policy that is routinely communicated to all healthcare staff Step 2 . Train all healthcare staff in the …

Linear and knemometric growth in the early phase of rehabilitation from severe malnutrition.

The relationship between ponderal, linear and lower leg growth in children recovering from severe malnutrition remains unclear. We report on the early growth of 141 severely malnourished Bangladeshi children aged 6 to 36 months of age who were followed for 90 d. Mean (sd) weight for height (WHZ) and height for age (HAZ) catch-up growth z scores over the 90 d were 1.6 (0.85) and 0.47 (0.325) respectively. Mean (sd) lower leg length growth was 10.35 (4.5) mm. Change in HAZ was significantly associated with initial WHZ, but linear growth occurred in the presence of severe wasting and no threshold WHZ score was identified. Lower leg length gain correlated throughout with ponderal indices but with change in HAZ score only after day 45. Only initial WHZ score and maternal height predicted for linear growth and only accounted for 20 % of total variance. We conclude that linear growth occurs early in severely malnourished children but that knemometry behaves as a ponderal index acutely.

How valuable are IgA and IgM anti-HIV tests for the diagnosis of mother-child transmission of HIV in an African setting?

BACKGROUND Babies born to HIV-infected mothers retain anti-HIV of maternal origin until 15-18 months of age. Because of this, HIV proviral DNA and p24 antigen measurements have become the methods of choice for timely diagnosis of HIV infection in infancy. They are, however, too expensive for widespread use in the developing world. OBJECTIVE To evaluate a simple, inexpensive serological method for diagnosing mother-child transmission of HIV, in an African population, which takes account of the effects of placental transfer of maternal antibody and continued exposure to HIV through breast-feeding. STUDY DESIGN Plasma specimens for a prospective study of mother-to-infant transmission of HIV in rural Zaire were collected at birth, 3, 6, 9, 12, 18 and 24 months from 21 infected infants (PP group), 21 uninfected infants (PN group) born to seropositive mothers and 21 control infants (NN group) born to uninfected mothers. The specimens were retrospectively tested for IgG, IgM and IgA anti-HIV by immunoglobulin class-specific capture EIAs, and by a commercial anti-HIV EIA. RESULTS In neonatal specimens, IgA and IgM anti-HIV were present, respectively, in 13 of 14 (97%) and 8 of 14 (57%) of the PP group and in 6 of 11 (55%) and 2 of 11 (18%) of the PN group. Later, at 3 months and older, IgA and IgM anti-HIV were only detected in the PP group. They peaked at 18 months (93%) and 24 months (67%) respectively. Of the 21 PP group children, 8 (38%) were transiently IgG anti-HIV-negative in the first year, indicating that infection had probably taken place after birth; four of the 8 had no detectable IgA anti-HIV during the first year. None of the specimens collected from the NN group babies were reactive for IgA, IgM or IgG anti-HIV. CONCLUSIONS IgA and IgM anti-HIV may be passively transferred across the placenta. Where breast-feeding is prevalent, about half of the transmissions may occur after birth, thus delaying the diagnosis of mother-child transmission. Nevertheless, this simple, cheap IgA anti-HIV, EIA identified 65% of transmissions by 9 months of age, and 93% at 18 months of age. It is a more useful marker than IgM anti-HIV, and gave a much more rapid answer than did tests for IgG anti-HIV seroreversion.

Lymphadenopathy and hepatosplenomegaly in the 1st year in children infected by HIV-1 in Zaire

The children of 50 women positive for antibody to human immunodeficiency virus type 1 (HIV-1) and 42 children of antibody-negative mothers were examined for lymphadenopathy and hepatosplenomegaly at 3-month intervals during the 1st year of life. Lymphadenopathy was found to be significantly more frequent at 6 months (p less than 0.01), 9 months (p less than 0.001) and 12 months (p less than 0.01) in children who were subsequently shown to be infected with HIV-1. Hepatomegaly was seen more frequently (p less than 0.05) in the 1st year in HIV-1-infected children than in uninfected children. Splenomegaly was not more frequent in HIV-1-infected children in this area which is holoendemic for falciparum malaria.

The portable Nabarro weight-height anthropometric nutrition assessment chart. A field trial in three countries in Africa

A cluster sampling technique and a portable weight-for-height measuring chart were used to conduct nutrition surveys on children between 12 and 60 months of age in rural communities in Tanzania, Zambia and Zaire. Wasting was uncommon. Only four (0.6%) of 644 children who were weighed and measured had a weight-for-height of less than 80% of the standard. The new chart classified all of these as wasted, along with five others whose weight-for-heights were close to 80% (80.2 to 83.3%). The portable weight-for-height chart works well, and the observer error was small. Compared with calculations from tables it did not fail to identify any of the significantly wasted children and gave five false positives, all in borderline cases. Simple modifications would make this chart easier to use.