Browsing by Author "Donald, Kirsten A"

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    Open Access
    An analysis of the prevalence of children with disabilities and disabling chronic illnesses in the Western health sub-district of Cape Town, and the services available for them
    (2014) Redfern, Andrew William; Donald, Kirsten A; Westwood, Anthony
    Children with disabling chronic illnesses are known to have complex and frequently unmet health care needs. Limited information exists in South Africa regarding the prevalence of children with disability, as well their needs and utilization of services. The purpose of the current study is twofold: (1) identify the number of children known with disability, or disabling chronic illnesses in the western health sub-district of Cape Town; (2) analyse the health services that currently exist for these children. A period prevalence survey was conducted between January 2010 and December 2011. Numerous sources of information were sought to identify as many children with disabling chronic illness as possible. These included the referral hospitals for the Western sub-district, namely Red Cross War Memorial Children's Hospital and New Somerset Hospital, as well as the institutions where children with disability are cared for or educated, and relevant non-profit organisations in the disability sector. Information was gathered between January 2011 and Sept 2012.
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    Growth, infectious morbidity, and neurodevelopment of HIV-exposed and HIV-unexposed infants in the context of lifelong maternal antiretroviral therapy and breastfeeding: a prospective cohort study
    (2021) Le Roux, Stanzi Maria; Myer, Landon; Donald, Kirsten A
    Background In 2019, 1 million in utero-HIV-exposed but -uninfected children (CHEU) were born in sub-Saharan Africa. In the absence of breastfeeding and maternal antiretroviral therapy (ART), HIV-exposed uninfected children (CHEU) have higher risks of mortality, growth faltering, infectious morbidity, and developmental delay than the general population, but data are limited on these outcomes among breastfed CHEU born to women who received universal (not restricted by disease severity) ART in pregnancy. This thesis addresses these knowledge gaps by comparing health outcomes of breastfed CHEU to breastfed CHU in the first year of life. Methods This research incorporates data from two prospective, linked cohort studies of pregnant women living with HIV (Maternal Child Health Antiretroviral, MCH-ART study, 2013-2016) and without HIV (HIV-unexposed uninfected, HU2 study; 2014-2017) in Gugulethu, Cape Town, South Africa. Enrolled at first antenatal visit at a primary care clinic, women were followed-up during pregnancy and postpartum with their breastfed infants, through 12 months with ~3-monthly study visits. Study staff administered questionnaires addressing maternal and child health, infant feeding, psycho-social and behavioural factors; and measured maternal-infant anthropometry [expressed as Z-scores for age: weight-for-age, WAZ; length-for-age, LAZ; head circumference-for-age, HCAZ]; WLHIV provided blood for repeated HIV viral load. At 12 months, the Bayley Scales of Infant Development, 3rd edition (BSID-III) was used to assess neurodevelopment. Findings WLHIV (100% antenatal ART) reported worse living conditions and higher risks of alcohol use and intimate partner violence than HIV-negative women. Similar proportions of CHEU and CHU were born preterm (11%) or small-for-gestational-age (10%). Exclusive breastfeeding was more common among CHEU than CHU, but overall duration of breastfeeding was shorter among CHEU. However, unless otherwise reported, adjustment for confounders did not change inferences below. In analysis of child growth, weight and head circumference trajectories were similar for CHEU and CHU from 6 weeks to 12 months. Both groups exhibited rapid weight gain with increasing WAZ over time; by 12 months, almost one-fifth of all children were overweight. Length trajectories for CHEU and CHU diverged after 6 months, with onset of linear growth faltering occurring earlier and more rapidly among the CHEU; by 12 months, stunting risk was doubled among CHEU vs CHU. Stratified by birth size, differences in LAZ between CHEU and CHU were magnified for those born small-forgestational age and absent for those born appropriate-for-gestational age. Infectious morbidity analyses revealed greater risks among CHEU than CHU in the first 6 months with not thereafter. Between 7 days and 3 months of life, CHEU (vs CHU) experienced three times more infection-related hospitalisations; rates for CHEU with healthier mothers (lower viral load, higher CD4 count, ART started early in pregnancy) approximated those of CHU, while CHEU of mothers with late ART initiation and advanced disease had four-fold more infectious-cause hospitalization. Breastfeeding and complete vaccinations were protective. At 12 months, mean composite cognitive, motor and language scores were within normal range and similar for both groups. Overall, risks of any developmental delays were low but slightly higher among CHEU than CHU in cognitive and motor domains. Compared to term HU, term HEU children had similar odds of motor delay, preterm HU children had 5-fold increased odds of delay and preterm HEU children, 16-fold. In CHEU, cumulative maternal viremia was associated with lower average scores and increased risk of moderate delays in motor and language domains. Conclusion Subtle health outcome differences persisted between CHEU and CHU despite breastfeeding and universal maternal ART in pregnancy. Reassuringly, the magnitudes of differences were small and predominantly associated with preventable factors including late ART initiation, advanced maternal disease stage, lack of breastfeeding, and incomplete vaccination. CHEU born too soon or too small were at highest risk of adverse outcomes, suggesting fetal origins of disease in the context of maternal HIV.
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    Open Access
    HIV Encephalopathy: pediatric case series description and insights from the clinic coalface
    (BioMed Central, 2015-01-17) Donald, Kirsten A; Walker, Kathleen G; Kilborn, Tracy; Carrara, Henri; Langerak, Nelleke G; Eley, Brian; Wilmshurst, Jo M
    Background: The Human Immune Deficiency Virus (HIV) can manifest neurologically in both adults and children. Early invasion of the central nervous system by the virus, affecting the developing brain, is believed to result in the most common primary HIV-related neurological complication, HIV Encephalopathy (HIVE). In countries such as South Africa where many children have not been initiated on antiretroviral treatment early, HIVE remains a significant clinical problem. Methods: Children were selected from a clinic for children with neurologic complications of HIV, located at the Red Cross War Memorial Children’s Hospital, South Africa 2008–2012. Eligible subjects fulfilled the following inclusion criteria: aged 6 months-13 years; positive diagnosis of HIV infection, vertically infected and HIVE as defined by CDC criteria. Each participant was prospectively assessed by a Pediatric Neurologist using a standardized proforma which collated relevant details of background, clinical and immunological status. Results: The median age of the 87 children was 64 months (interquartile range 27–95 months). All except one child were on antiretroviral treatment, 45% had commenced treatment <12 months of age. Delayed early motor milestones were reported in 80% and delayed early speech in 75% of children in whom we had the information. Twenty percent had a history of one or more seizures and 41% had a history of behavior problems. Forty-eight percent had microcephaly and 63% a spastic diplegia. CD4 percentages followed a normal distribution with mean of 30.3% (SD 8.69). Viral loads were undetectable (
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    Intergenerational effects: child and maternal outcomes related to exposure to intimate partner violence and trauma in a South African community
    (2021) Barnett, Whitney Christine; Stein, Dan J; Donald, Kirsten A; Halligan, Sarah
    Intimate partner violence (IPV) constitutes a major global health problem, affecting one in three women worldwide at some point during their life. IPV is particularly high in low and middle income countries (LMICs) and is associated with a wide range of adverse maternal and child health outcomes. Despite evidence that exposure to IPV affects child development and growth at birth and in infancy, there are limitations to our existing knowledge. First, few studies have considered the impact of maternal emotional IPV separately on child outcomes investigated, focusing primarily on physical and/or sexual IPV. Second, much of the existing data derives from high income countries, rather than from LMIC settings, where the majority of the world's child population lives and where many children are exposed to disproportionately high levels of poverty and violence-related risk factors. Third, there is limited information from well characterized longitudinal studies in these settings and a lack of investigation of associations in very young children, despite the fact that children under 2 years may be particularly at risk for long-term health sequelae relating to IPV exposure. Lastly, few studies have formally investigated potential mediators, inclusive of both behavioral and biological mechanisms underlying associations between IPV and food security and early-life child growth or development. In high-risk settings such as South Africa it is critical to gain improved understanding of pathways by which violence affects child health. This may be especially important given that LMIC contexts often have fewer programs in place to address IPV, and that associated mental health issues and risk factors may be different than in higher income countries. This thesis aimed to investigate IPV in a South African birth cohort, the Drakenstein Child Health Cohort, to understand better the patterns of IPV amongst pregnant and postpartum women, the impact antenatal and postnatal IPV exposure may have on their child's growth and development, and the pathways by which IPV may impact child health sequelae. Chapter 1 reviews the relevant literature, discusses key gaps and presents thesis aims and structure. Chapter 2 comprises a methods chapter which provides an overview of the study population, measures and ethical considerations. Chapter 3 (Paper 1) presents longitudinal profiles of maternal IPV exposure by sub-type from pregnancy through 24 months post-partum and associations between maternal childhood maltreatment and longitudinal frequency and severity of IPV. Chapter 4 (Paper 2) investigates the association between maternal childhood trauma as well as IPV and food insecurity among pregnant women, and examines whether maternal depression mediates these relationships. Chapter 5 (Paper 3) investigates associations between IPV sub-types and growth at birth and 12 months. Further, multiple psychosocial (substance use, depression) and clinical factors (number of hospitalizations) are tested to determine whether any of these may be mediators in the relationship between IPV and child growth. Chapter 6 (Paper 4) investigates emotional, physical and sexual IPV and their relationship with child development at 24 months of age, and whether depression or maternal alcohol dependence mediates these relationships. Chapter 7 presents a summary of findings across results chapters and includes recommendations for future policy and research. Key findings in this population show that: i) a high proportion of mothers are exposed to chronic IPV during and after pregnancy and that maternal childhood abuse or neglect is associated with higher frequency and severity of IPV exposure; ii) maternal IPV and childhood trauma are each associated with food insecurity during pregnancy and that depression partially explains these relationships; iii) emotional and physical IPV are associated with reduced fetal growth and reduced growth through infancy, and maternal substance use (alcohol or tobacco) partially explains these relationships; iv) both emotional and physical IPV are associated with poorer child development at 2 years, and neither maternal current depression nor alcohol dependence explain these relationships. Overall, the findings highlight that emotional IPV in addition to physical IPV is a key risk factor for child growth and development, and identify potential pathways underlying explored relationships. Maternal depression and substance use emerged as partial explanatory variables for nutritional outcomes, specifically food insecurity during pregnancy and growth outcomes at birth and through infancy. The high prevalence of IPV and its negative impact on child health, together comprise a major public health problem, causing significant hardship and representing a significant burden for families, economies and health systems. Findings presented in this thesis suggest that comprehensive and intersectoral programs are needed to 5 address IPV and associated adverse child health outcomes, inclusive of efforts to address maternal mental health and substance use. Further, it is also vital to ensure emotional IPV is included in training and intervention efforts. Clinical implications and areas for future research are discussed.
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    Maternal methamphetamine use during pregnancy and subsequent neurodevelopmental and psychological sequelae in the child - a Cape Town experience
    (2011) Van Dyk, Jessi Grace; Ramanjam, Veruschka; Donald, Kirsten A
    Methamphetamine, part of the amphetamine group of drugs, was first discovered in Japan in 1919. It has been clandestinely manufactured in the United States since the 1960s, and is still legally produced there as a nasal inhalant, as treatment for Attention Deficit Disorder and exogenous obesity, as well as off-label treatment for narcolepsy. (1) It is a cheap (about R15- 30 per 'straw'), easily obtainable, odourless, white powder, which has a bitter, taste, but dissolves easily in water or alcohol. Known as, amongst others, ' speed', 'ice', 'crystal', 'chalk', 'glass', 'crank', and locally, 'tik', it can be smoked, snorted, orally ingested, injected intravenously or even administered anally. In South Africa the preferred method consists of placing the powder or crystal in a light bulb (from which the metal threading has been removed) and inhaling the fumes produced while heating the bulb from below with a lighter.(2). The use of methamphetamine has risen sharply globally over the last decade, used by 26 million people worldwide by 2007, more than heroin and cocaine combined, according to the United Nations Office on Drugs and Crime. This has been ascribed to many interlocking reasons: it is cheap, easily obtainable, easy to use without the need for needles or other special 'equipment', and it produces in the user a characteristic 'rush'. This feeling of confidence, power and heightened sexual levels, of feeling 'on top of the world' has made it especially popular amongst teenagers and young adults. (3)
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    Prenatal alcohol exposure and the early neurodevelopmental outcomes of children in a South African birth cohort study
    (2020) Hendricks, Gaironeesa; Donald, Kirsten A; Malcolm-Smith, Susan; Stein, Dan J
    Introduction: Over the last few decades, prenatal alcohol exposure (PAE) has been a major public health problem both globally and in low- to-middle-income countries (LMICs) such as South Africa. Pregnant women and new mothers are particularly vulnerable; and PAE may be associated with adverse child neurodevelopmental outcomes. However, few studies have explored the association of PAE, including risk factors, and subsequent neurodevelopmental trajectories over multiple timepoints in the early years. Given the high burden of PAE and associated risk factors, and the relative paucity of empirical data, further work in South African populations is warranted. This thesis aimed to investigate the association between PAE and early neurodevelopmental outcomes in the Drakenstein Child Health Study (DCHS), a South African birth cohort. The specific objectives included: 1. a systematic review on the available longitudinal studies exploring the impact of PAE on language, speech and communication development (Chapter 3 Manuscript 1); 2. an exploration of the association between PAE and motor, language and cognitive outcomes in infancy (Chapter 4- Manuscript 2); 3. an investigation of the association between PAE, including interactions of tobacco smoking exposure, and the neurodevelopmental trajectories (motor, language and cognitive outcomes) of children across the first 4 years of life (Chapter 5 Manuscript 3); 4. a comparison of the conversational turn-taking between mothers and their alcohol exposed children compared to those between mothers and their unexposed children (Chapter 6 Manuscript 4). Methods: This thesis included four publications, three of which present data from the DCHS. Pregnant women were enrolled from two public primary healthcare clinics, Mbekweni (a predominantly black African population) and TC Newman (a mixed-ancestry population), and more than 1000 mother-child dyads were followed longitudinally from birth through the first 5 years of life. For this study, both antenatal and postnatal maternal measures were used to assess moderate-to-severe levels of PAE. These measures included the (i) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) antenatally, (ii) a retrospective alcohol questionnaire in the postnatal period at 3-6 weeks and/or 24 months testing age. At 6, 24 and 42 months, early neurodevelopmental outcomes were assessed using the Bayley-III Scales of Infant Development (BSID-III), the Kaufman Assessment Battery for Children (KABC-II) or the Peabody Picture Vocabulary Test (PPVT-IV). Conversational turn-taking in mother-child dyads was also assessed at 42 months testing age. Both univariate and multivariate analyses were used to analyse the data. Results: The findings of this thesisshowed that PAE was significantly associated with both fine motor (B=-3.30, 95%CI 0.06-0.46, p=0.001) and gross motor scores (B=-0.30, 95%CI 0.06-0.44 p=0.001) at 6 months (Chapter 4 Manuscript 2). Chapter 5 (Manuscript 3) showed that when accounting for the interaction between prenatal alcohol and tobacco smoking exposure, impaired fine motor functioning occurred up till 24 months (B=-12.59, 95%CI -21.98- -3.19, p=0.01), but these effects attenuated by 42 months. Significant interactions occurred between prenatal alcohol, including tobacco smoking exposure, and impaired receptive vocabulary (B=-2.49, 95%CI -5.24 -0.27, p=0.02) and cognitive functioning at 24 months (B=- 3.25, 95%CI -5.98- -0.52, p=0.02) (Chapter 5 Manuscript 3). Finally, when exploring conversational turn-taking in alcohol exposed mother-child dyads and unexposed dyads, PAE was significantly associated with conversational turn-taking i.e. child overlapping utterances (OR=3.25, CI 0.98-10.76, p=0.050) (Chapter 6 Manuscript 4). Conclusion: The associations of PAE with early neurodevelopmental outcomes shown here expand on the previous literature. Our findings reported that PAE may influence early neurodevelopmental outcomes, however, future studies should include additional longitudinal studies to replicate the findings, and ongoing follow-up of our own cohort may continue clarify the potential association of PAE and additional risk factors on later neurodevelopmental outcomes at school age and beyond. Effective alcohol programmes targeting pregnant women and interventions to address child developmental impairments in this vulnerable cohort are required.
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    The validation of a new development screening tool for developmental delays among HIV-Infected South African children
    (2015) Boyede, Ojombo Gbemisola; Donald, Kirsten A; Eley, Brian
    Background: Over 50% of HIV-infected children in South Africa have developmental delays. Early identification of affected children will lead to early intervention and favourable long-term outcome. Screening for developmental delay is not yet routine by many primary healthcare providers due to lack of locally available, rapid and sensitive screening tool s in busy Paediatric HIV clinics. A new screening tool was developed at the Red Cross War Memorial Children's Hospital (RCWMCH) for detecting moderate to severe global developmental delay among very young HIV infected children. The diagnostic accuracy and usefulness of the new tool was evaluated in this study. Objective: to validate the new RCWMCH developmental screening too l among HIV - infected South African children. Method: Forty-seven HIV-infected children in the age category 9-36 months attending the Infectious Disease Clinic (IDC) of the RCWMCH were screened using the new tool. Full developmental assessments of same children were performed using the Bayley Scale of Infant Development (BSID - III). Developmental Delay (global) was defined as composite scores 2 standard deviations below the mean in two or more developmental domains. Results: The sensitivity of the RCWMCH tool was 78.5%, specificity 54.6%, positive predictive value was 42.6%, and negative predictive value was 85. 7 %. Discussion: The RCWMCH screening tool was found to have sensitivity within the acceptable levels recommended for developmental screening tools. Its high negative predictive value will reduce unnecessary referrals for full developmental assessments in asymptomatic infants and toddlers. It is therefore recommended for screening for developmental delay among HIV-infected children from the age of 9 months to 3 years.