Browsing by Subject "Children"

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    A functional balance profile of school aged children and adolescents diagnosed with Down Syndrome, schooled in the Eastern Cape province of South Africa: a pilot study.
    (2025) Nolte, Cilje; Rogers, Christine
    Children and adolescents with Down Syndrome (DS) are at a higher risk of falls due to impaired balance and gait patterns, which complicates their ability to safely engage in daily activities (Jung, Chung & Lee, 2017). Assessing balance function in children is not only important for identifying balance deficits, but also to inform and highlight integral areas of balance function that should be addressed during rehabilitation. Although various outcome measures have demonstrated acceptable reliability and validity in typically developing children, the applicability of outcome measures in children with DS has not been fully established. This pilot study aimed to evaluate the clinimetric properties, including reliability, validity, and practicality, of four functional balance outcome measures: the Paediatric Balance Scale (PBS), the second edition of the Bruininks-Oseretsky Test of Motor Proficiency (BOT-2, Subtest 5), the full Children's Balance Evaluation Systems Test (Kids- BESTest), and its shortened version (Kids Mini-BESTest). To contextualise the results, a control group of age- and sex-matched typically developing peers was included for comparison. The primary objectives were to assess reliability (inter-rater and test-retest), known-groups validity, criterion validity (via correlations with Timed Up & Go (TUG) scores), and internal consistency (using Cronbach's alpha) of each measure. Outcome measures used in real-world settings like schools and clinics require qualities beyond being clinimetrially sound. Aspects regarding the practical applicability of these outcome measures should also be considered. Thus, this study evaluated the accessibility, safety, and practicality of administering these tests in a DS population, including time requirements, cost-effectiveness, and participant acceptability. The secondary objectives were to describe the balance profile of the DS group and explore the effects of potential confounders, including middle ear function, cochlear outer hair cell function, and Body Mass Index (BMI), on balance performance and test outcomes. Children from the Merryvale School for Special Education in Gqeberha, Eastern Cape (EC), South Africa (SA), participated in this study, while typically developing controls were sourced from local schools in the same area. Safety measures, such as gait belts and close guarding, were implemented to ensure participant safety and minimise fall risk during assessments. Data confidentiality and participant welfare were prioritised throughout the study. The results demonstrated significant differences in balance performance between children with DS and typically developing peers across all four assessment tools. The DS group exhibited lower mean scores and shorter durations for balance tasks, with notable floor effects in specific items, particularly within the Kids-BESTest and PBS. Independent t-tests revealed statistically significant group differences (p < 0.001), with large effect sizes (e.g., Cohen's d = 3.94 for BOT-2 Subtest 5). Reliability analysis showed good inter-rater and test-retest reliability for all tools, with Cronbach's alpha values ranging from 0.867 to 0.971, indicating strong internal consistency. Validity testing confirmed known-groups validity, with balance assessments effectively differentiating between DS and typically developing groups, while criterion validity demonstrated a significant association between balance test scores and TUG performance (e.g., Kids-BESTest R² = 0.536, p < 0.001). Health-related variables, such as BMI and middle ear status, significantly correlated with poorer balance outcomes. This correlation further emphasises the multifactorial nature of balance impairments in children with DS. This study offers initial insights into effective, safe balance assessment methods which audiologists can use for DS populations. These insights ultimately pave the way for future research to support balance related interventions.
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    A longitudinal study on possible correlates that might explain the onset and progression of musculoskeletal symptoms in school-aged children with Generalized Joint Hypermobility
    (2025) Ituen, Oluwakemi Adebukola; Ferguson, Gillian; Smits-Engelsman, Bouwien; Akwaowo, Christie; Duysens, Jacques
    Background: Generalized Joint Hypermobility (GJH) is an increased joint range of motion in multiple joints. Its prevalence in the general population is usually a function of age, gender, ethnicity and Beighton score cut-off score. GJH has been documented to be beneficial to sports and activities that require flexibility. Despite this advantage, it is assumed that joint laxity distorts joint biomechanics increasing their risk of injuries and pain. This has remained inconclusive in the literature because not all children with GJH develop musculoskeletal pain. In addition, previous studies have tested proprioception, balance and strength as possible underlying factors facilitating the onset of musculoskeletal symptoms in GJH. Yet, studies using different instruments and test positions have been inconclusive about the association. In addition, the psychosocial consequence of GJH is yet to be explored. Our study was aimed at following up on the same group of children, taking three assessments of proprioception, functional strength and dynamic balance over a period of two years and investigating how they may influence the development of musculoskeletal symptoms in school-aged children with GJH. The children's physical fitness, functional difficulties, physical activity levels and quality of life were also measured during the study period. Methods: A prospective longitudinal study design was used. We recruited 198 children aged 6-8 years at the beginning of the study. We classified them based on their joint mobility using the Beighton scoring system with goniometry. Strength, dynamic balance, physical fitness and proprioception were assessed using the Functional Strength Measurement, Y-Balance, Shuttle run test and Wedges test, respectively. The Child Activity Limitation Interview questionnaire version 21 (CALI-21) was used to document functional difficulties; the Physical Activity questionnaire was used to evaluate the children's physical activity level, while the children's quality of life was determined using the Pediatric Quality of Life questionnaire. The Wong-Baker FACES was used to determine the participants' pain level. Results: A total at 195 children entered the study and 69 were lost to follow-up due to relocation or change of school at the end of the study. Proprioception, strength and balance were not different between mobility groups at the end of the study. Physical activity levels between children with and without GJH were significantly different at the end of the study. The overall quality of life was not different between the mobility groups. Conclusion: We found a high prevalence of GJH (64.7%), and the inclusion of goniometry in the Beighton scoring system provided more specific information on joint hypermobility. None of the children with joint hypermobility developed HSD. The incidence of pain among children with GJH was so low that factors (proprioception, balance, or strength) mentioned in the literature could not be used to predict the onset of musculoskeletal symptoms in GJH. Contrary to previous findings in the literature, children with GJH in our study were not different in proprioception, dynamic balance, and functional strength compared to children with normal mobility. The outcome of this longitudinal study confirms that these factors (proprioception, dynamic balance, and functional strength) do not contribute to the onset of musculoskeletal symptoms in school-aged children with GJH, thus preventing inappropriate interventions. Despite the significant decline in physical activity in children with GJH over time, they were not different from their normal mobile counterparts in functional difficulties, physical fitness and quality of life.
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    A review of the use of inhaled nitric oxide in the PICU at Red Cross Children's Hospital, 2011-2015: A retrospective cohort study
    (2019) Padayachee, Sandhia; Salie, Shamiel
    Background: Inhaled Nitric Oxide (iNO) functions as a selective pulmonary vasodilator. It is an expensive treatment that is often employed as rescue therapy for refractory hypoxaemia in acute respiratory distress syndrome (ARDS) and pulmonary hypertension (PHT) following cardiac surgery. Objectives: To describe the response to treatment with iNO. Secondary observations were deaths, comorbidities of the patients treated, lengths of treatment and admission, and the cost of treatment. Methods: A retrospective descriptive study of all patients treated with iNO in the Paediatric Intensive Care Unit (PICU) at Red Cross War Memorial Children’s Hospital (RCWMCH) from 2011- 2015. Results: A total of 140 patients were treated with iNO during this time period, 82 were for PHT following cardiac surgery, 53 for ARDS and 5 for PPHN. A response to treatment was observed in 64% of the cohort as a whole, 80% of those with PPHN, 67% of those with PHT post-cardiac surgery, and 64% of those with ARDS. A longer duration of ICU and hospital admission, and higher in hospital mortality (53%) was seen in the group with ARDS, in particular those with adenoviral infection (63%), when compared to patients treated for PHT (18%) and for PPHN (20%). There is no protocol in place guiding the use of iNO in our unit, and it was found that response to treatment was not being objectively measured and documented and that practise varied between clinicians. Conclusions: Considering the cost of treatment and lack of evidence to support beneficial effects of iNO therapy, its continued use in our resource poor setting should be guided by protocol.
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    Added sugar, macro-and micronutrient intakes and anthropometry of children in a developing world context
    (Public Library of Science, 2015) Maunder, Eleni M W; Nel, Johanna H; Steyn, Nelia P; Kruger, H Salome; Labadarios, Demetre
    Objective The objective of this study was to determine the relationship between added sugar and dietary diversity, micronutrient intakes and anthropometric status in a nationally representative study of children, 1-8.9 years of age in South Africa. METHODS: Secondary analysis of a national survey of children (weighted n = 2,200; non weighted n = 2818) was undertaken. Validated 24-hour recalls of children were collected from mothers/caregivers and stratified into quartiles of percentage energy from added sugar (% EAS). A dietary diversity score (DDS) using 9 food groups, a food variety score (FVS) of individual food items, and a mean adequacy ratio (MAR) based on 11 micronutrients were calculated. The prevalence of stunting and overweight/obesity was also determined. RESULTS: Added sugar intake varied from 7.5-10.3% of energy intake for rural and urban areas, respectively. Mean added sugar intake ranged from 1.0% of energy intake in Quartile 1 (1-3 years) (Q1) to 19.3% in Q4 (4-8 years). Main sources of added sugar were white sugar (60.1%), cool drinks (squash type) (10.4%) and carbonated cool drinks (6.0%). Added sugar intake, correlated positively with most micronutrient intakes, DDS, FVS, and MAR. Significant negative partial correlations, adjusted for energy intake, were found between added sugar intake and intakes of protein, fibre, thiamin, pantothenic acid, biotin, vitamin E, calcium (1-3 years), phosphorus, iron (4-8 years), magnesium and zinc. The prevalence of overweight/obesity was higher in children aged 4-8 years in Q4 of %EAS than in other quartiles [mean (95%CI) % prevalence overweight 23.0 (16.2-29.8)% in Q4 compared to 13.0 (8.7-17.3)% in Q1, p = 0.0063]. CONCLUSION: Although DDS, FVS, MAR and micronutrient intakes were positively correlated with added sugar intakes, overall negative associations between micronutrients and added sugar intakes, adjusted for dietary energy, indicate micronutrient dilution. Overweight/obesity was increased with higher added sugar intakes in the 4-8 year old children.
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    Analysis of The Demographics, Pathways to Diagnosis, Burden of Disease and Long-term Outcomes of Patients with Spinal Muscular Atrophy Managed at Red Cross War Memorial Children's Hospital
    (2025) Mkhize, Nondumiso; Wilmshurst, Joanne; Raga, Sharika
    Spinal muscular atrophy (SMA) is an autosomal recessive disorder of anterior horn cell degeneration which results in symmetrical muscle weakness that affects multiple systems. This study was conducted to determine the burden of disease of SMA on children under the neuromuscular service at Red Cross War Memorial Children's Hospital. A quantitative retrospective audit identified 86 DNA confirmed patients with SMA who attended the service from 2000 to August 2023. Thirty-six medical folders were accessible, 6 were excluded and 50 had been destroyed. An in-depth analysis of 30 folders showed a median age of diagnosis of 3.5 months for SMA1 (4 patients), 19 months for SMA2 (17 patients) and 34 months for SMA3 (9 patients). Five patients had demised and 4 were transferred to adult services. Over the study period, 172 chest infections were reported among the 30 children with SMA. Forty-three percent required home ventilation, 70% had scoliosis, 70% had contractures, 33% received feeding support via a percutaneous endoscopic gastrostomy tube and 44% of SMA3 patients had lost ambulation. Our SMA numbers are less than expected and delays in diagnosis were common. Strategies to improve diagnosis and minimize delays are needed and retaining medical records will provide more comprehensive insights on the long-term outcomes.
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    Aspects of laryngotracheobronchitis in African children
    (1972) Wesley, Anne Gardiner
    "Laryngotracheobronchitis" is a relatively recent term for infective upper airway disease (Baum, 1924). Prior to this "croup" was used by both public and profession to describe a train of laryngeal symptoms which sometimes were due to infection. The word derives from the Anglosaxon "kropan" (Neffson and Wishik, 1934a) or "hreopan" (MacKenzie, 1880) and although used earlier by Blair (MacKenzie, 1880; Eisner, 1959), was popularised in 1765 by the Scottish physician Home (Cormack, 18750). Both used the term in descriptions of what was probably diphtheria.
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    Azithromycin versus placebo for the treatment of HIV-associated chronic lung disease in children and adolescents (BREATHE trial): study protocol for a randomised controlled trial
    (BioMed Central, 2017-12-28) Gonzalez-Martinez, Carmen; Kranzer, Katharina; McHugh, Grace; Corbett, Elizabeth L; Mujuru, Hilda; Nicol, Mark P; Rowland-Jones, Sarah; Rehman, Andrea M; Gutteberg, Tore J; Flaegstad, Trond; Odland, Jon O; Ferrand, Rashida A
    Background: Human immunodeficiency virus (HIV)-related chronic lung disease (CLD) among children is associated with substantial morbidity, despite antiretroviral therapy. This may be a consequence of repeated respiratory tract infections and/or dysregulated immune activation that accompanies HIV infection. Macrolides have anti-inflammatory and antimicrobial properties, and we hypothesised that azithromycin would reduce decline in lung function and morbidity through preventing respiratory tract infections and controlling systemic inflammation. Methods/design: We are conducting a multicentre (Malawi and Zimbabwe), double-blind, randomised controlled trial of a 12-month course of weekly azithromycin versus placebo. The primary outcome is the mean change in forced expiratory volume in 1 second (FEV1) z-score at 12 months. Participants are followed up to 18 months to explore the durability of effect. Secondary outcomes are FEV1 z-score at 18 months, time to death, time to first acute respiratory exacerbation, number of exacerbations, number of hospitalisations, weight for age z-score at 12 and 18 months, number of adverse events, number of malaria episodes, number of bloodstream Salmonella typhi infections and number of gastroenteritis episodes. Participants will be followed up 3-monthly, and lung function will be assessed every 6 months. Laboratory substudies will be done to investigate the impact of azithromycin on systemic inflammation and on development of antimicrobial resistance as well as impact on the nasopharyngeal, lung and gut microbiome. Discussion: The results of this trial will be of clinical relevance because there are no established guidelines on the treatment and management of HIV-associated CLD in children in sub-Saharan Africa, where 80% of the world’s HIVinfected children live and where HIV-associated CLD is highly prevalent. Trial registration: ClinicalTrials.gov, NCT02426112. Registered on 21 April 2015.
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    Bacterial disease and antimicrobial susceptibility patterns in HIV-infected, hospitalized children: a retrospective cohort study
    (Public Library of Science, 2008) Jaspan, Heather B; Huang, Lyen C; Cotton, Mark F; Whitelaw, Andrew; Myer, Landon
    BACKGROUND: Serious bacterial infections are a major source of morbidity and mortality in HIV-infected children. The spectrum of disease is wide, and responsible organisms vary according to setting. The use of antibiotic prophylaxis and the emergence of multi-drug resistant bacteria necessitate examination of responsible organisms and their antibiotic susceptibility. METHODOLOGY/PRINCIPAL FINDINGS: A retrospective cohort study of all HIV-positive pediatric admissions at an urban public sector hospital in Cape Town between January 2002 and June 2006 was conducted. Children between the ages of one month and nine years with laboratory confirmed HIV status, serious bacterial infection, and a hospital length of stay of 5 days or more, were eligible for inclusion. Organisms isolated from blood, urine, and cerebral spinal fluid cultures and their antimicrobial susceptibility were examined, and compared according to timing of isolation to distinguish nosocomial versus community-acquired. One hundred and forty-one children were identified (median age 1.2 years), 39% of whom were on antiretrovirals started before or during this hospitalization. Bacterial infections involved all organ systems, however pneumonia was most common (67%). S. pneumoniae and S. aureus were the most common gram positive and K. pneumoniae was the most common gram negative organism. K pneumoniae isolates were resistant to many first and second line antibiotics, and were all considered nosocomial. All S. aureus isolates were methicillin resistant, some of which were community-acquired. Conclusions/Significance Bacterial infections are an important source of co-morbidity in HIV-infected children in resource-limited settings. Clinicians should have a low threshold to initiate antibiotics in children requiring hospitalization. Broad-spectrum antibiotics should be used judiciously. Clinicians caring for HIV-infected children should be cognizant of the most common organisms affecting such children, and of their local antimicrobial susceptibilities, when treating empirically for serious bacterial infections.
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    Bloodstream infections at a tertiary level paediatric hospital in South Africa
    (2017) Eley, Brian
    BACKGROUND: Bloodstream infection (BSI) in children causes significant morbidity and mortality. There are few studies describing the epidemiology of BSI in South African children. METHODS: A retrospective descriptive cohort study was conducted at a paediatric referral hospital in Cape Town, South Africa. The National Health Laboratory Service (NHLS) microbiology database was accessed to identify positive blood culture specimens during the period 2011-2012. Demographic and clinical details, antimicrobial management and patient outcome information were extracted from medical and laboratory records. Antibiotic susceptibility results of identified organisms were obtained from the NHLS database. RESULTS: Of the 693 unique bacterial and fungal BSI episodes identified during the study period, 248 (35.8%) were community-acquired (CA), 371 (53.5%) hospital-acquired (HA) and 74 (10.7%) healthcare-associated (HCA). The overall risk was 6.7 BSI episodes per 1000 admissions. Escherichia coli, Staphylococcus aureus and Streptococcus pneumoniae were the most frequent causes of CA-BSI and Klebsiella pneumoniae, Acinetobacter baumanii and S.aureus were most commonly isolated in HA-BSI. On multivariable analysis, severe underweight, severe anaemia at the time of BSI, admission in the ICU at the time of BSI, and requiring ICU admission after BSI was diagnosed were significantly associated with 14-day mortality. CONCLUSION: This study adds to the limited literature describing BSI in children in Africa. Further studies are required to understand the impact that BSI has on the paediatric population in sub-Saharan Africa.
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    Bloodstream infections at a tertiary level paediatric hospital in South Africa
    (BioMed Central, 2017-12-06) Lochan, Harsha; Pillay, Vashini; Bamford, Colleen; Nuttall, James; Eley, Brian
    Background: Bloodstream infection (BSI) in children causes significant morbidity and mortality. There are few studies describing the epidemiology of BSI in South African children. Methods: A retrospective descriptive cohort study was conducted at a paediatric referral hospital in Cape Town, South Africa. The National Health Laboratory Service (NHLS) microbiology database was accessed to identify positive blood culture specimens during the period 2011–2012. Demographic and clinical details, antimicrobial management and patient outcome information were extracted from medical and laboratory records. Antibiotic susceptibility results of identified organisms were obtained from the NHLS database. Results: Of the 693 unique bacterial and fungal BSI episodes identified during the study period, 248 (35.8%) were community-acquired (CA), 371 (53.5%) hospital-acquired (HA) and 74 (10.7%) healthcare-associated (HCA). The overall risk was 6.7 BSI episodes per 1000 admissions. Escherichia coli, Staphylococcus aureus and Streptococcus pneumoniae were the most frequent causes of CA-BSI and Klebsiella pneumoniae, Acinetobacter baumanii and S. aureus were most commonly isolated in HA-BSI. On multivariable analysis, severe underweight, severe anaemia at the time of BSI, admission in the ICU at the time of BSI, and requiring ICU admission after BSI was diagnosed were significantly associated with 14-day mortality. Conclusion: This study adds to the limited literature describing BSI in children in Africa. Further studies are required to understand the impact that BSI has on the paediatric population in sub-Saharan Africa.
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    Can social protection improve Sustainable Development Goals for adolescent health?
    (Public Library of Science, 2016) Cluver, Lucie D; Orkin, F Mark; Meinck, Franziska; Boyes, Mark E; Yakubovich, Alexa R; Sherr, Lorraine
    BACKGROUND: The first policy action outlined in the Sustainable Development Goals (SDGs) is the implementation of national social protection systems. This study assesses whether social protection provision can impact 17 indicators of five key health-related SDG goals amongst adolescents in South Africa. METHODS: We conducted a longitudinal survey of adolescents (10-18 years) between 2009 and 2012. Census areas were randomly selected in two urban and two rural health districts in two South African provinces, including all homes with a resident adolescent. Household receipt of social protection in the form of 'cash' (economic provision) and 'care' (psychosocial support) social protection, and health-related indicators within five SDG goals were assessed. Gender-disaggregated analyses included multivariate logistic regression, testing for interactions between social protection and socio-demographic covariates, and marginal effects models. FINDINGS: Social protection was associated with significant adolescent risk reductions in 12 of 17 gender-disaggregated SDG indicators, spanning SDG 2 (hunger); SDG 3 (AIDS, tuberculosis, mental health and substance abuse); SDG 4 (educational access); SDG 5 (sexual exploitation, sexual and reproductive health); and SDG 16 (violence perpetration). For six of 17 indicators, combined cash plus care showed enhanced risk reduction effects. Two interactions showed that effects of care varied by poverty level for boys' hunger and girls' school dropout. For tuberculosis, and for boys' sexual exploitation and girls' mental health and violence perpetration, no effects were found and more targeted or creative means will be needed to reach adolescents on these challenging burdens. Interpretation National social protection systems are not a panacea, but findings suggest that they have multiple and synergistic positive associations with adolescent health outcomes. Such systems may help us rise to the challenges of health and sustainable development.
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    CD8+ T-cell interleukin-7 receptor alpha expression as a potential indicator of disease status in HIV-infected children
    (Public Library of Science, 2008) Sharma, Tanvi S; Hughes, Jane; Murillo, Amarylis; Riley, Joanne; Soares, Andreia; Little, Francesca; Mitchell, Charles D; Hanekom, Willem A
    BACKGROUND: Initiation and modification of antiretroviral therapy in HIV-infected children depend on viral load and CD4+ T-cell count. However, these surrogates have limitations, and complementary immunological markers to assess therapeutic response are needed. Our aim was to evaluate CD8+ T-cell expression of CD127 as a marker of disease status in HIV-infected children, based on adult data suggesting its usefulness. We hypothesized that CD127 expression on CD8+ T-cells is lower in children with more advanced disease. METHODS: In a cross-sectional evaluation, we used flow cytometry to measure CD127+ expression on CD8+ T-cells in whole blood from HIV-infected children with varying disease status. This was compared with expression of CD38 on this subset, currently used in clinical practice as a marker of disease status. RESULTS: 51 HIV-infected children were enrolled. There was a strong positive correlation between CD127 expression on CD8+ T-cells and CD4+ T-cell count, and height and weight z-scores, and a strong negative correlation between CD127 expression and viral load. In contrast, we found no association between CD38 expression and these disease status markers. CONCLUSIONS: CD8+ T-cell CD127 expression is significantly higher in children with better HIV disease control, and may have a role as an immunologic indicator of disease status. Longitudinal studies are needed to determine the utility of this marker as a potential indicator of HIV disease progression.
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    Child mental health in Sierra Leone: a survey and exploratory qualitative study
    (2016) Yoder, Hélène N C; Tol, Wietse A; Reis, Ria; de Jong, Joop T V M
    Abstract Background This study complements the growing amount of research on the psychosocial impact of war on children in Sierra Leone by examining local perceptions of child mental health, formal and informal care systems, help-seeking behaviour and stigma. Methods The study combined: (1) a nationwide survey of mental health care providers, with (2) exploratory qualitative research among service users and providers and other stakeholders concerned with child and adolescent mental health, with a particular emphasis on local explanations and stigma. Results Formal mental health care services are extremely limited resulting in an estimated treatment gap of over 99.8 %. Local explanations of child mental health problems in Sierra Leone are commonly spiritual or supernatural in nature, and associated with help-seeking from traditional healers or religious institutions. There is a considerable amount of stigma related to mental disorders, which affects children, their caregivers and service providers, and may lead to discrimination and abuse. Conclusions Child and Adolescent Mental Health (CAMH) care development in Sierra Leone should cater to the long-term structural effects of war-violence and an Ebola epidemic. Priorities for development include: (1) the strengthening of legal structures and the development of relevant policies that strengthen the health system and specifically include children and adolescents, (2) a clearer local distinction between children with psychiatric, neurological, developmental or psychosocial problems and subsequent channelling into appropriate services (3) supplementary CAMH training for a range of professionals working with children across various sectors, (4) specialist training in CAMH, (5) integration of CAMH care into primary health care, education and the social welfare system, (6) further research on local explanations of child mental disorders and the effect they have on the well-being of the child, and (7) a careful consideration of the role of religious healers as care providers.
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    Children’s route choice during active transportation to school: difference between shortest and actual route
    (2016) Dessing, Dirk; de Vries, Sanne I; Hegeman, Geertje; Verhagen, Evert; van Mechelen, Willem; Pierik, Frank H
    BackgroundThe purpose of this study is to increase our understanding of environmental correlates that are associated with route choice during active transportation to school (ATS) by comparing characteristics of actual walking and cycling routes between home and school with the shortest possible route to school.MethodsChildren (n = 184; 86 boys, 98 girls; age range: 8–12 years) from seven schools in suburban municipalities in the Netherlands participated in the study. Actual walking and cycling routes to school were measured with a GPS-device that children wore during an entire school week. Measurements were conducted in the period April–June 2014. Route characteristics for both actual and shortest routes between home and school were determined for a buffer of 25m from the routes and divided into four categories: Land use (residential, commercial, recreational, traffic areas), Aesthetics (presence of greenery/natural water ways along route), Traffic (safety measures such as traffic lights, zebra crossings, speed bumps) and Type of street (pedestrian, cycling, residential streets, arterial roads). Comparison of characteristics of shortest and actual routes was performed with conditional logistic regression models.ResultsMedian distance of the actual walking routes was 390.1m, whereas median distance of actual cycling routes was 673.9m. Actual walking and cycling routes were not significantly longer than the shortest possible routes. Children mainly traveled through residential areas on their way to school (>80% of the route). Traffic lights were found to be positively associated with route choice during ATS. Zebra crossings were less often present along the actual routes (walking: OR = 0.17, 95 % CI = 0.05–0.58; cycling: OR = 0.31, 95 % CI = 0.14–0.67), and streets with a high occurrence of accidents were less often used during cycling to school (OR = 0.57, 95% CI = 0.43–0.76). Moreover, percentage of visible surface water along the actual route was higher compared to the shortest routes (walking: OR = 1.04, 95 % CI = 1.01–1.07; cycling: OR = 1.03, 95 % CI = 1.01–1.05).DiscussionThis study showed a novel approach to examine built environmental exposure during active transport to school. Most of the results of the study suggest that children avoid to walk or cycle along busy roads on their way to school.Electronic supplementary materialThe online version of this article (doi:10.1186/s12966-016-0373-y) contains supplementary material, which is available to authorized users.
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    Clinical characteristics and outcomes of children with rheumatic heart disease: a global rheumatic heart disease registry (REMEDY) sub-analysis
    (2021) Makate, Sindiswa A; Zühlke, Lisel Joanna
    Background: Despite Rheumatic Heart Disease (RHD) contributing to an estimated disease burden in 2019 of 40 million people and 285 500 deaths, few studies document the characteristics and outcomes in children. We undertook a sub-analysis of children from the multi-centre prospective two-year global Rheumatic Heart Disease Registry (REMEDY) to document their presentation, clinical characteristics and outcomes. Methods: Nine-hundred and twenty-one children were enrolled into the REMEDY registry among the 3,343 symptomatic RHD patients from 25 hospitals in 12 African countries, India and Yemen and followed up over 24 months to assess characteristics, complications and outcome. Results: More than half of the children enrolled in the REMEDY study presented with severe valvular heart disease; 60% had more than one valve involved, 30% were classified as NYHA class III/IV and 17.7% died within 24 months. Just over 20% of children were not on penicillin prophylaxis. Although 20% met criteria for surgery, only less than 9% (n=78, 8.5%) had had percutaneous or surgical intervention with half from upper-middle-income countries. The major risk factors associated with mortality included older age (Hazard Ratio (HR): 1.01, p=0.001) and atrial fibrillation or flutter (HR: 2.3, p=0.028). Female gender(HR: 0.68, p=0.062) and education level above primary school (HR: 0.88, p=0.68) did not confer significant protection. However, a past medical history of ARF conferred some protection against mortality (HR: 0.61, p=0.031). In follow-up, 30% (n=238, 29.6%) of children experienced an adverse cardiovascular event, nearly 15% (n=114, 14.1%) were hospitalised and six young women became pregnant during the study period. Conclusion: Children with RHD in low- and middle-income countries are severely affected, with significant mortality and morbidity. The use of penicillin was suboptimal and the substantial need for surgery is evident. Our findings support the recommendations of the World Health Assembly (WHA) Resolution 71.14 passed in May 2018 for consistent provision of penicillin, integrated collaborative efforts focused on children and adolescent health as well as access to specialised services including cardiac surgery.
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    Clinical mentorship of nurse initiated antiretroviral therapy in Khayelitsha, South Africa: a quality of care assessment
    (Public Library of Science, 2014) Green, Ann; de Azevedo, Virginia; Patten, Gabriela; Davies, Mary-Ann; Ibeto, Mary; Cox, Vivian
    Introduction To combat the AIDS epidemic and increase HIV treatment access, the South African government implemented a nurse-based, doctor-supported model of care that decentralizes administration of antiretroviral treatment (ART) for HIV positive patients through nurse initiated and managed ART. Médecins Sans Frontières (MSF) implemented a mentorship programme to ensure successful task-shifting, subsequently assessing the quality of clinical care provided by nurses. METHODS: A before-after cross-sectional study was conducted on nurses completing the mentorship programme in Khayelitsha, South Africa, from February 2011-September 2012. Routine clinical data from 229 patient folders and 21 self-assessment questionnaires was collected to determine the number of patients initiated on ART by nurses; quality of ART management before-after mentorship; patient characteristics for doctor and nurse ART initiations; and nurse self-assessments after mentorship. RESULTS: Twenty one nurses were authorized by one nurse mentor with one part-time medical officer's support, resulting in nurses initiating 77% of ART eligible patients. Improvements in ART management were found for drawing required bloods (91% vs 99%, p = 0.03), assessing adherence (50% vs 78%, p<0.001) and WHO staging (63% vs 91%, p<0.001). Nurse ART initiation indicators were successfully completed at 95-100% for 11 of 16 indicators: clinical presentation; patient weight; baseline blood work (CD4, creatinine, haemoglobin); STI screening; WHO stage, correlating medical history; medications prescribed appropriately; ART start date; and documented return date. Doctors initiated more patients with TB/HIV co-infection and WHO Stage 3 and 4 disease than nurses. Nurse confidence improved for managing HIV-infected children and pregnant women, blood result interpretation and long-term side effects. CONCLUSIONS: Implementation of a clinical mentorship programme in Khayelitsha led to nurse initiation of a majority of eligible patients, enabling medical officers to manage complex cases. As mentorship can increase clinical confidence and enhance professional development, it should be considered essential for universal ART access in resource limited settings.
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    Co-creating a culturally relevant programme for enabling participation of children with brain injury in Uganda (CEBU)
    (2025) Ekwan, Francis Uzu; Sonday, Amshuda; Gretschel, Pamela Joy; Pamela Joy
    Background: The Culturally Relevant Programme Enabling Participation of Children with Brain Injury in Uganda was co-created to address the occupational needs of children with brain injury aged four months to 17 years, as well as the well-being of their caregivers. Aim and Purpose: The aim of this thesis was to co-create a culturally relevant programme for enabling participation of children with brain injury in Uganda and describe its co-creation process. The purpose was to improve children's activity functioning and survival following brain injury, and impact on caregivers' health. Methods: Three studies were implemented in two phases following participatory action research design. Phase one explored the participants' thoughts, feelings, and perceptions of the usual intervention in Kampala-Wakiso Brain Injury Home: Therapy Centre (KWB-HTC) Uganda. In phase two, a culturally relevant programme enabling participation of children with brain injury was co-created; its consequences and limitations described. Purposive selection of primary participants (eight brain injured children) and general participants (eleven health professionals and three caregivers) took place. Video data were collected from each primary participant in the usual intervention, action changes. Interview data were collected from general participants in group reflection and individual interview. Thematic analysis was used to analyse data collected. Findings: Thematic analysis of data collected identified three main themes: The first theme, “an intervention that does not satisfy basic needs,” linked to three sub-themes: “ignorance of child's condition,” “assessment that does not focus on functional issues,” and “unwitting goals.” The second theme, “bridging basic needs and enablement,” linked to three sub-themes: “assessing child enablement contexts,” “supporting caregivers to attain psychological health,” and “involving the child in daily life activities.” The third theme, “diversifying daily life participation,” linked to two sub-themes: “forming community connectedness,” and “moderating caregiver constraints.” Conclusion: In conclusion, every child with brain injury in Uganda deserves an intervention that satisfies basic needs, co-created as the Four-star Model for Enablement and Participation. To implement the Four-star Model, this thesis proposed Occupation Actualization (OA) philosophy which requires children with brain injury to be involved in daily life activities formed by occupation scale and occupation score. The Occupation Actualization philosophy assumes that there is a positive relationship between occupation scale, occupation score, and enablement within the guiding principles of the Four-star Model delivered through community connectedness at the African One Hospital. Further research is recommended to implement and evaluate the effectiveness of the Four-star Model in Uganda, and test the validity of the OA philosophy.
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    A comparative analysis of polyfunctional T cells and secreted cytokines induced by Bacille Calmette-Guerin immunisation in children and adults
    (Public Library of Science, 2012) Ritz, Nicole; Strach, Madeleine; Yau, Carmen; Dutta, Binita; Tebruegge, Marc; Connell, Tom G; Hanekom, Willem A; Britton, Warwick J; Robins-Browne, Roy; Curtis, Nigel
    BCG vaccine is one of the most commonly-administered vaccines worldwide. Studies suggest the protective efficacy of BCG against TB is better for children than for adults. One potential explanation is that BCG induces a better protective immune response in children. Twenty six children and adults were immunised with BCG. The proportion of Th1-cytokine-producing mycobacterial-specific T cells, and the concentrations of secreted cytokines, were measured before and 10 weeks after BCG immunisation. A significant increase in the proportion of mycobacterial-specific cytokine-producing T cells was observed in both age groups. After BCG immunisation, children and adults had comparable proportions of mycobacterial-specific polyfunctional CD4 T cells when measured relative to the total number of CD4 T cells. However, relative to the subset of Th-1-cytokine-producing CD4 T cells, the proportion of polyfunctional cells was greater in children. Concentrations of secreted cytokines were comparable in children and adults. These findings suggest that the mycobacterial-specific cell-mediated immune response induced by BCG immunisation in children and adults is similar. The implication of a shift to a more polyfunctional immune response within the Th1-cytokine-producing CD4 T cells in children is uncertain as this aspect of the immune response has not been assessed as a potential correlate of protection against TB.
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    Comparison of mantoux and tine tuberculin skin tests in BCG-vaccinated children investigated for tuberculosis
    (Public Library of Science, 2009) Pan, Wenli; Matizirofa, Lyness; Workman, Lesley; Hawkridge, Tony; Hanekom, Willem; Mahomed, Hassan; Hussey, Gregory; Hatherill, Mark
    Background: Tuberculin skin tests (TSTs) are long-established screening methods for tuberculosis (TB). We aimed to compare agreement between the intradermal Mantoux and multipuncture percutaneous Tine methods and to quantify risk factors for a positive test result. Methodology/Principal Findings: 1512 South African children younger than 5 years of age who were investigated for tuberculosis (TB) during a Bacille Calmette Guerin (BCG) trial were included in this analysis. Children underwent both Mantoux and Tine tests. A positive test was defined as Mantoux ≥15 mm or Tine ≥ Grade 3 for the binary comparison. Agreement was evaluated using kappa (binary) and weighted kappa (hierarchical). Multivariate regression models identified independent risk factors for TST positivity. The Mantoux test was positive in 430 children (28.4%) and the Tine test in 496 children (32.8%, p<0.0001), with observed binary agreement 87.3% (kappa 0.70) and hierarchical agreement 85.0% (weighted kappa 0.66). Among 173 children culture-positive for Mycobacterium tuberculosis, Mantoux was positive in 49.1% and Tine in 54.9%, p<0.0001 (kappa 0.70). Evidence of digit preference was noted for Mantoux readings at 5 mm threshold intervals. After adjustment for confounders, a positive culture, suggestive chest radiograph, and proximity of TB contact were risk factors for a positive test using both TST methods. There were no independent associations between ethnicity, gender, age, or over-crowding, and TST result. Conclusions/Significance: The Tine test demonstrated a higher positive test rate than the Mantoux, with substantial agreement between TST methods among young BCG-vaccinated children. TB disease and exposure factors, but not demographic variables, were independent risk factors for a positive result using either test method. These findings suggest that the Tine might be a useful screening tool for childhood TB in resource-limited countries.
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    A Cost-Effectiveness Analysis of a Program to Control Rheumatic Fever and Rheumatic Heart Disease in Pinar del Rio, Cuba
    (Public Library of Science, 2015) Watkins, David A; Mvundura, Mercy; Nordet, Porfirio; Mayosi, Bongani M
    BACKGROUND: Acute rheumatic fever (ARF) and rheumatic heart disease (RHD) persist in many low- and middle-income countries. To date, the cost-effectiveness of population-based, combined primary and secondary prevention strategies has not been assessed. In the Pinar del Rio province of Cuba, a comprehensive ARF/RHD control program was undertaken over 1986 - 1996. The present study analyzes the cost-effectiveness of this Cuban program. Methods and FINDINGS: We developed a decision tree model based on the natural history of ARF/RHD, comparing the costs and effectiveness of the 10-year Cuban program to a “do nothing” approach. Our population of interest was the cohort of children aged 5 - 24 years resident in Pinar del Rio in 1986. We assessed costs and health outcomes over a lifetime horizon, and we took the healthcare system perspective on costs but did not apply a discount rate. We used epidemiologic, clinical, and direct medical cost inputs that were previously collected for publications on the Cuban program. We estimated health gains as disability-adjusted life years (DALYs) averted using standard approaches developed for the Global Burden of Disease studies. Cost-effectiveness acceptability thresholds were defined by one and three times per capita gross domestic product per DALY averted. We also conducted an uncertainty analysis using Monte Carlo simulations and several scenario analyses exploring the impact of alternative assumptions about the program’s effects and costs. We found that, compared to doing nothing, the Cuban program averted 5051 DALYs (1844 per 100,000 school-aged children) and saved $7,848,590 (2010 USD) despite a total program cost of $202,890 over 10 years. In the scenario analyses, the program remained cost saving when a lower level of effectiveness and a reduction in averted years of life lost were assumed. In a worst-case scenario including 20-fold higher costs, the program still had a 100% of being cost-effective and an 85% chance of being cost saving. CONCLUSIONS: A 10-year program to control ARF/RHD in Pinar del Rio, Cuba dramatically reduced morbidity and premature mortality in children and young adults and was cost saving. The results of our analysis were robust to higher program costs and more conservative assumptions about the program’s effectiveness. It is possible that the program’s effectiveness resulted from synergies between primary and secondary prevention strategies. The findings of this study have implications for non-communicable disease policymaking in other resource-limited settings.