South African paediatric food-based dietary guidelines

South African efforts to address both under- and overnutrition , and other nutrition-related public health issues, utilizing food-based dietary guidelines (FBDGs) as an educational tool, are introduced. However, the focus is placed on the development of paediatric FBDGs for infants and young children, from birth up to the age of 7 years, and how these were made compatible with scientific and local public health evidence on the one hand, and existing South African FBDGs for children over the age of 7 years, adolescents and adults, on the other. Members of the Working Group and other stakeholders are gratefully acknowledged.     

The process followed in the development of the paediatric food-based dietary guidelines for South Africa

In 1996, a Food and Agricultural Organization/World Health Organization expert panel proposed the development of food-based dietary guidelines (FBDGs) that would be unique and specific to the needs of the populations of different countries. In 1997, a South African FBDG Working Group was initiated to develop a single set of FBDGs aimed at optimal nutrition for all South Africans older than 5 years. Thereafter, additional working groups investigated the development of FBDGs for specific priority groups including HIV/AIDS sufferers, the elderly, pregnant and lactating women and children under 5 years. This resulted in the formation of an expert paediatric FBDG Working Group in 2000, in Cape Town with the task to develop paediatric FBDGs (PFBDGs) for children younger than 5 years. However, it was decided to raise the 5-year-age limit to 7 years, which corresponds to one of the recommended dietary allowance (RDA) cut-offs for both genders and that would cover most pre-schoolers. Ultimately, three age subcategories were identified for developing specific PFBDGs, i.e. 0-6 months, 6-12 months and 12-84 months. In May 2003, after thorough review of the relevant literature, discussions with various stakeholders and pre-testing for comprehensibility, a set of preliminary PFBDGs for each of the subcategories was approved by the Working Group to be subjected to consumer testing. The proposed guidelines were considered to be the most appropriate ones for each age group, based on scientific and local evidence, and were evaluated utilizing qualitative methodologies. The results of these data are presented and discussed below. However, further testing is required for the diverse groups in the country.     

Addressing malnutrition in young children in South Africa. Setting the national context for paediatric food-based dietary guidelines

Despite various national nutrition and primary healthcare programmes being initiated in South Africa over the last decade, child health has deteriorated. This is seen by the rise in infant and child mortality rates, the high prevalence of preventable childhood diseases, e.g. diarrhoea and lower respiratory tract infections, and the coexistence of under-nutrition along with HIV/AIDS. Poor dietary intake, food insecurity and poor quality of basic services prevail within this precarious causal web. The national Integrated Nutrition Programme is a comprehensive nutrition strategy that focuses on children below 6 years old, at-risk pregnant and lactating women, and those affected by communicable and non-communicable diseases. Focus areas relevant to pre-school children include disease-specific nutrition treatment, support and counselling; growth monitoring and promotion (GMP); micronutrient malnutrition control; breastfeeding promotion, protection and support; contributions to household food security; nutrition interventions among HIV-infected children; and nutrition promotion, education and advocacy. Progress towards this includes the Baby-Friendly Hospital Initiative; mandatory fortification of maize meal and wheat flour with multiple micronutrients; vitamin A supplementation coverage and mandatory iodization of salt by legislation; the provision of free road-to-health charts for GMP; and the National School Nutrition Programme. Since 2003, the basis of the nutrition education strategy has been the locally developed food-based dietary guidelines (FBDGs), directed at adults and school-going children. This review sketches the backdrop to and motivation for the introduction of specifically targeted paediatric FBDGs, for mothers and caregivers of children from birth to age 7 years, as a national initiative.     

Nutrition and HIV/AIDS in infants and children in South Africa: implications for food-based dietary guidelines

The implications for food-based dietary guidelines (FBDGs) that are being developed in South Africa are reviewed in relation to HIV-exposed and -infected children. The nutritional consequences of HIV infection and nutritional requirements along with programmes and guidelines to address undernutrition and micronutrient deficiency in these children are also investigated. Based on studies for HIV-infected children in South Africa, more than 50% are underweight and stunted, while more than 60% have multiple micronutrient deficiencies. Nutritional problems in these children are currently addressed through the Prevention-of-Mother-to-Child Transmission Programme (PMTCT), the Integrated Nutrition Programme and Guidelines for the Management of HIV-infected Children which include antiretroviral (ARV) therapy in South Africa. Evaluations relating to the implementation of these programmes and guidelines have not been conducted nationally, although certain studies show that coverage of the PMTCT and the ARV therapy programmes was low. FBDGs for infants and young children could complement and strengthen the implementation of these programmes and guidelines. However, FBDGs must be in line with national and international guidelines and address key nutritional issues in these infants and young children. These issues and various recommendations are discussed in detail in this review.     

Nutrition, oral health and the young child

Oral health is integral to general health and essential to well-being and quality of life. Socio-behavioural and environmental factors play a significant role in oral disease and oral health. Dental caries is a global disease with few populations exempt from its effects. In developing countries, as development increases so does dental caries and children are at the forefront of the disease disadvantage. There is a growing need to identify high caries risk groups accurately to commence prevention from a young age. The effect of early intervention in childhood on general and dental health with both population and high-risk approaches also needs examining. As an educational tool, the paediatric food-based dietary guidelines may play a significant role in nutrition and oral health interventions. This paper provides information on nutrition, including access to fluoride and use of sugar. Oral health concerns, such as early childhood caries, which are important for the young child, are also discussed.     

The rationale for adopting current international breastfeeding guidelines in South Africa

Current international breastfeeding guidelines recommend exclusive breastfeeding for 6 months, followed by the appropriate and adequate introduction of complementary foods at 6 months, with continued breastfeeding for 2 years and beyond. This guideline is based on evidence to support exclusive and extended breastfeeding as the optimal method of feeding infants and young children. Not only do these breastfeeding practices meet the nutrition needs of infants and children for optimal growth and development, but they also offer a host of other health and socio-economic benefits at all levels of society. The poor breastfeeding rates and increase in infant and child morbidity and mortality in South Africa have led to increased prioritized attention towards the promotion, protection and support of breastfeeding. In 2000, the National Department of Health formally adopted the international breastfeeding guidelines for exclusive and extended breastfeeding practices. Therefore, it remains a priority to implement these guidelines in all current and future breastfeeding programmes and interventions, including the South African paediatric food-based dietary guidelines.     

Food-based dietary guidelines and nutrition interventions for children at primary healthcare facilities in South Africa

Existing dietary recommendations and nutrition counselling provided to mothers/caregivers at primary healthcare (PHC) facilities are reviewed and analysed to be consistent with food-based dietary guidelines (FBDGs) that are being developed for preschool children. Recommendations provided by the Integrated Management of Childhood Illness and the provincial Paediatric Case Management Guidelines, which are currently implemented at PHC facilities were reviewed. For FBDGs to be consistent with nutrition counselling that is provided to mothers/caregivers at these facilities, various principles need to be promoted. These include among others, exclusive and on-demand breastfeeding in the HIV-negative mother; exclusive breastfeeding with abrupt cessation preferably at 6 months or exclusive, safe and adequate formula feeding in the HIV-infected mother; the introduction of complementary feeds in all infants at 6 months; the provision of energy-dense and micronutrient-enriched (particularly, iron, zinc, calcium and vitamin A) complementary feeds; frequent visits to the healthcare facility; and physical activity aimed at encouraging a healthy lifestyle and preventing overweight and obesity in childhood. The FBDGs should be incorporated into nutrition and child health programmes and be reviewed and modified regularly.     

'It's not just about food': mother-infant interaction and the wider context of nutrition

In recent years, attention has increasingly focused on the wider context of nutrition, rather than simply on calorie and nutrient intake. Recent estimates put the figure of people in the world living in extreme poverty (an income of less than $1 a day) at 1.1 billion. This has significant implications for nutritional deficiencies in infants and young children. In this paper, we will show how the physical growth and psychological development of infants and children are intimately linked, and how many of the same aetiological factors (such as caregiver sensitivity, psychosocial support, communicative exchange between infant/child and their caregiver) are implicated in both domains. Preliminary evidence indicates that community-based interventions impact on the mother-infant relationship as well as infant physical growth, and contribute to the increasing sense of how aspects of the early relationship between infants and their caretakers are crucial to any complete understanding of infant growth and development. The paediatric food-based dietary guidelines (PFBDGs) include guidelines relating to the mother-infant relationship and may thus prove to be a significant tool in community interventions.     

Perceptions of the characteristics of the Alberta Nutrition Guidelines for Children and Youth by child care providers may influence early adoption of nutrition guidelines in child care centres

In 2008, the Alberta government released the Alberta Nutrition Guidelines for Children and Youth (ANGCY) as a resource for child care facilities to translate nutrition recommendations into practical food choices. Using a multiple case study method, early adoption of the guidelines was examined in two child care centres in Alberta, Canada. Key constructs from the Diffusion of Innovations framework were used to develop an interview protocol based on the perceived characteristics of the guidelines (relative advantage, compatibility, complexity, trialability and observability) by child care providers. Analysis of the ANGCY was conducted by a trained qualitative researcher and validated by an external qualitative researcher. This entailed reviewing guideline content, layout, organisation, presentation, format, comprehensiveness and dissemination to understand whether characteristics of the guidelines affect the adoption process. Data were collected through direct observation, key informant interviews and documentation of field notes. Qualitative data were analysed using content analysis. Overall, the guidelines were perceived positively by child care providers. Child care providers found the guidelines to have a high relative advantage, be compatible with current practice, have a low level of complexity, easy to try and easy to observe changes. It is valuable to understand how child care providers perceive characteristics of guidelines as this is the first step in identifying the needs of child care providers with respect to early adoption and identifying potential educational strategies important for dissemination.     

Bone mass accretion rates in pre- and early-pubertal South African black and white children in relation to habitual physical activity and dietary calcium intakes

AIM: To examine bone mass changes in 321 black and white South African children in relation to habitual physical activity (PA) levels and calcium intakes. METHODS: Children underwent two bone mass scans at ages nine and 10 years using dual X-Ray absorptiometry. PA levels and calcium intakes were assessed using questionnaires. Data were analyzed by regressing change in bone mineral content (BMC) and bone area (BA) from age nine to 10, against BA (for BMC), height and body weight. The residuals were saved and called residualized BMCGAIN and BAGAIN. Residualized values provide good indication of weight, height and BA-matched accumulation rates. RESULTS: White children had significantly higher PA levels and calcium intakes than black children. Most active white males had significantly higher residualized BMCGAIN and BAGAIN at the whole body, hip and spine but not at the radius, than those who were less active. Most active white females had significantly higher residualized BAGAIN at all sites except the radius than less-active girls. No such effects were seen in black children. There was no interactive effect on residualized BMCGAIN for calcium intake and PA (except at the spine in white girls). CONCLUSION: Bone mass and area gain is accentuated in pre- and early-pubertal children with highest levels of habitual physical activity. Limited evidence of an effect of dietary calcium intakes on BMC was found.     

Bereavement support for families following the death of a child from cancer: practice characteristics of Australian and New Zealand paediatric oncology units

OBJECTIVE: The impact of childhood cancer on the patient and family is devastating and results in significant emotional and physical effects on the child and family. An increasing awareness of the role of health care professionals at this time has led to the development of hospital-based bereavement support services. However, many services are not evidence based, and family support varies between institutions. The objective of this study was to determine current practice relating to hospital-based bereavement support programmes. METHODS: A survey of all major tertiary paediatric oncology units in Australia and New Zealand (N = 10) was undertaken. The survey instrument consisted of a 19-item questionnaire with open-ended and closed questions. RESULTS: Nine hospitals (90%) participated. Most hospitals provided a multidisciplinary bereavement service for approximately one year after a child's death. Programmes varied, but the most common hospital-based supports provided were counselling and support groups. Important findings were: a significant number of hospitals worked from a limited theoretical basis and understanding, did not screen for high risk of complicated grieving, did not formally evaluate their programme, and identified areas of unmet needs. CONCLUSION: The majority of paediatric oncology units in Australia and New Zealand provide dedicated multidisciplinary bereavement support services. There is variation in services provided, often due to a lack of resources and staffing. Findings indicate a need to further develop bereavement programmes, improve staff education and support, and increase the availability of resources in this area. Future research should explore the needs of bereaved families, as well as the range of services and evaluation methods that could be implemented as the baseline for 'best practice' hospital-based bereavement programmes.     

Liver is widely eaten by preschool children in the Northern Cape province of South Africa: Implications for routine vitamin A supplementation

Previous research has demonstrated a virtual absence of vitamin A deficiency and adequacy of vitamin A intake through consumption of liver in preschool children of a community in the Northern Cape province of South Africa where sheep farming is common, and liver, an exceptionally rich source of vitamin A, is frequently eaten. Only 60–75 g of liver per month is needed to meet the vitamin A requirement of preschool children. Because this may have implications for routine vitamin A supplementation, and because liver consumption for the rest of the province is unknown, the study aim was to establish the prevalence and frequency of liver intake in a provincial‐wide survey. An unquantified liver‐specific food frequency questionnaire, covering a period of 1 month, complemented by a 1‐year recall, was administered to mothers of 2‐ to 5‐year‐old children (n = 2,864) attending primary health care facilities in all five districts and 26 subdistricts. A total of 86% of children were reported to eat liver, which was eaten in all districts by at least 80% of children. The overall median frequency of liver intake was 1.0 [25th, 75th percentiles: 0.5, 3.0] times per month and ranged from 1.0 [0.3, 2.0] to 2.0 [1.0, 4.0] for the various districts. Based on a previously reported portion size of 66 g, these results suggest vitamin A dietary adequacy in all districts and possibly also vitamin A intake exceeding the Tolerable Upper Intake Level in some children. Routine vitamin A supplementation in this province may not be necessary and should be reconsidered.     

Determinants of adherence to a single‐dose nevirapine regimen for the prevention of mother‐to‐child HIV transmission in Gert Sibande district in South Africa

Aim: To identify factors that influence adherence to antiretroviral (ARV) prophylaxis by HIV positive mothers participating in the HIV prevention of mother to child (PMTCT) programme. Methods: Post‐delivery 815 HIV‐infected mothers aged 18 years and above with babies aged 3–6 months were interviewed in Gert Sibande District, Mpumalanga province, South Africa. Results: Eighty five percent of the mothers indicated that they had been provided with nevirapine and 78.4% took it before or at the onset of labour and infant nevirapine intake was 76.9%. In multivariate analysis it was found that women with better PMTCT knowledge had a higher perceived confidentility about HIV status at the health facility. They had a term delivery and those who had told their partner about nevirapine had a higher maternal nevirapine adherence. Women who had also told their partner about nevirapine, whose partner was asked for an HIV test and those who knew the HIV status of their infant had higher infant nevirapine adherence. Conclusion: Adherence to maternal and infant ARV prophylaxis was found to be sub‐optimal. Health services delivery factors, male involvement, communication and social support contribute to adherence to ARV prophylaxis in this largely rural setting in South Africa.     

A 7-year-old child with primary tumour localisation in the distal duodenum – new imaging procedures for an improved diagnosis

Duodenal gastrinomas in childhood are extremely rare and often missed at first medical consultation. We report on a 7-year-old child with sporadic gastrinoma of primary localisation in the distal duodenum. Small metastases in the liver and regional nodes were detected pre-operatively by somatostatin receptor scintigraphy (SRS) but not by other conventional imaging procedures. Diagnostic procedures include pre-operative SRS, endoscopic ultrasound and intra-operative endoscopic transillumination. Conclusion Gastrinomas are rare abdominal tumours in childhood. Pre-operative tumour-specific diagnosis is possible by ¹¹¹indium pentreotide SRS. Received: 9 May 1996 / Accepted: 21 October 1996     

Child poverty. Ways forward for the paediatrician: A comprehensive overview of poverty reduction strategies requiring paediatric support

The harmful effects of child poverty are well documented. Despite this, progress in poverty reduction in Canada has been slow. A significant gap exists between what is known about eradicating poverty and its implementation. Paediatricians can play an important role in bridging this gap by understanding and advancing child poverty reduction. Establishment of a comprehensive national poverty reduction plan is essential to improving progress. The present review identifies the key components of an effective poverty reduction strategy. These elements include effective poverty screening, promoting healthy child development and readiness to learn, ensuring food and housing security, providing extended health care coverage for the uninsured and using place-based solutions and team-level interventions. Specific economic interventions are also reviewed. Addressing the social determinants of health in these ways is crucial to narrowing disparities in wealth and health so that all children in Canada reach their full potential.     

Sodium intake of 1 to 5-year-old children: the STRIP project. The Special Turku Coronary Risk Factor Intervention Project

The aim of this study is to examine sodium intake and dietary sodium sources of 1-5-y-old children in a prospective, randomized long-term coronary heart disease prevention trial, focused on dietary fat modification. Counselling included no advice about reducing salt in the children's diets. Food consumption of 100 intervention children and 100 control children was recorded for 3 consecutive days at the age of 13 mo and for 4 consecutive days at the ages of 3 and 5 y. Sodium intakes were calculated using the Micro Nutrica program. Children's mean daily sodium (NaCl) consumption (intervention and control children combined) was 1600 ± 527 mg (4.0 ± 1.3 g), 1900 ± 504 mg (4.8 ± 1.3 g) and 2200 ± 531 mg (5.5 ± 1.3 g) at the ages of 13 mo and 3 and 5 y, respectively. The intervention children consumed as much or slightly more sodium than the control children at all ages studied. Half the sodium consumption was derived from added salt in commercially prepared or homemade foods. Milk, meat products, bread and cereals were other important sodium sources. In conclusion, nutrition counselling in the Special Turku Coronary Risk Factor Intervention Project (STRIP) trial, with its main focus on the quality of fat in child nutrition, has had minimal influence on children's sodium intake. To avoid excessive sodium intake in children, dietary counselling should include information about salt use, and food manufacturers should be encouraged to provide more low-sodium products.     

A worldwide collaboration to harmonize guidelines for the long‐term follow‐up of childhood and young adult cancer survivors: A report from the international late effects of Childhood Cancer Guideline Harmonization Group

Childhood and young adult cancer survivors should receive optimum care to reduce the consequences of late effects and improve quality of life. We can facilitate achieving this goal by international collaboration in guideline development. In 2010, the International Late Effects of Childhood Cancer Guideline Harmonization Group was initiated. The aim of the harmonization endeavor is to establish a common vision and integrated strategy for the surveillance of late effects in childhood and young adult cancer survivors. With the implementation of our evidence‐based methods, we provide a framework for the harmonization of guidelines for the long‐term follow‐up of childhood and young adult cancer survivors. Pediatr Blood Cancer 2013; 60: 543–549. © 2012 Wiley Periodicals, Inc.     

The feasibility of implementing Toronto childhood cancer stage guidelines and estimating the impact on outcome for childhood cancers in seven pediatric oncology units in sub-Saharan Africa. A study from the Franco-African Pediatric Oncology Group

Background

The improvement of childhood cancer outcome is determined by early diagnosis, effective treatment, supportive care, and adequate medical follow-up. Stage at diagnosis may reflect timeliness of diagnosis, therefore standardized registration of stage is essential for interpretation of regional differences and time trends in survival. Here, we describe the feasibility of implementing the Toronto Childhood Cancer Stage Guidelines (hereafter Toronto Guidelines [TG]) in the hospital-based cancer registry of the Franco-African Pediatric Oncology Group (GFAOP), and assess the impact of TG stage on outcome in pediatric oncology units (POUs) in seven low- and middle-income countries in sub-Saharan Africa (SSA).

Methods

All cancer patients diagnosed before 15 years of age with one of the 15 cancer types defined in TG, resident in one of the participating countries, and attending one of the selected POUs in 2017–2019 were included. Stage was assigned according to TG. Patients were followed-up for vital status for at least 12 months post diagnosis. Survival at 3, 6, and 12 months was calculated using Kaplan–Meier method and compared between POUs and tumor groups using log-rank test.

Results

TG stage was assigned to 1772 of 2446 (89%) cases diagnosed with one of 11 cancer types. It was not possible to assign TG stage to acute lymphoblastic leukemia (ALL) and the three types of the central nervous system tumors included in the TG. One-year overall survival (OS) was 58% [95% confidence interval: 55–60] and varied between POUs. Survival declined with increasing stage for four tumor types and was statistically significant for two.

Conclusion

Except for ALL and brain tumors, we demonstrated feasibility of TG implementation for childhood solid cancers in participating POUs in SSA, and provided a baseline assessment of childhood cancer outcomes against which future stage distribution and survival can be measured as timelines of diagnosis improve over time within the GFAOP network.