Perspectives of normal child development in rural Malawi – a qualitative analysis to create a more culturally appropriate developmental assessment tool

Background Child development in developing countries is often evaluated using assessment tools created for ‘Western’ settings. Recent work has demonstrated that, for certain developmental milestones, ‘Western’ tools may be inaccurate as they include items unfamiliar to children of different cultural settings. Methods We used qualitative methods to gather information about normal development in an African setting. Ten village and two professional focus group discussions (FGDs) were conducted. We used purposive sampling methods to recruit groups of mothers, grandmothers and men in four areas of Southern Malawi for village FGDs. Separate FGDs were carried out with professionals working in areas relating to child development. A thematic content analysis established main patterns and themes and dissemination of results and continued feedback allowed for respondent validation and reflection of results. The information then gathered was used to create questions for a revised Malawian developmental assessment tool. Results Social and gross motor milestones were the main focus of interest for village and professional FGDs with the latter creating new language and fine motor concepts. Social milestones highlighted included ‘duties and chores’, ‘sharing’ and ‘taking up leadership roles’. Language milestones included ‘reporting events’ and ‘shrugging to indicate no’ and fine motor milestones included ‘peeling bananas’, ‘sorting maize’ and ‘making patterns with bottle tops’. Intelligence was described in relation to social and community integrity rather than ‘Western’ concepts of numeracy and literacy. Conclusions Concepts, ideas and language relating to normal development in a sub‐Saharan African setting have been gathered in this study. These have been used to create items for a more culturally appropriate developmental assessment tool.     

Patterns of Body Composition Among HIV-Infected, Pregnant Malawians and the Effects of Famine Season

We describe change in weight, midupper arm circumference (MUAC), arm muscle area (AMA) and arm fat area (AFA) in 1130 pregnant HIV-infected women with CD4 counts > 200 as part of the BAN Study (www.thebanstudy.org), a randomized, controlled clinical trial to evaluate antiretroviral and nutrition interventions to reduce mother-to-child transmission of HIV during breast feeding. In a longitudinal analysis, we found a linear increase in weight with a mean rate of weight gain of 0.27 kgs/week, from baseline (12 to 30 weeks gestation) until the last follow-up visit (32–38 weeks). Analysis of weight gain showed that 17.1% of the intervals between visits resulted in a weight loss. In unadjusted models, MUAC and AMA increased and AFA declined during late pregnancy. Based on multivariable regression analysis, exposure to the famine season resulted in larger losses in AMA [?0.08, 95% CI ?0.14, ?0.02; p = 0.01] while AFA losses occurred irrespective of season [?0.55, 95%: ?0.95, ?0.14, p = 0.01]. CD4 was associated with AFA [0.21, 95% CI 0.01, 0.41, p = .04]. Age was positively associated with MUAC and AMA. Wealth was positively associated with MUAC, AFA, and weight. While patterns of anthropometric measures among HIV-infected, pregnant women were found to be similar to those reported for uninfected women in sub-Saharan Africa, effects of the famine season among undernourished, Malawian women are of concern. Strategies to optimize nutrition during pregnancy for these women appear warranted.     

Bacteremia in Malawian children with severe malaria: prevalence, etiology, HIV coinfection, and outcome

BACKGROUND: Previous prospective studies of bacteremia in African children with severe malaria have mainly included children with cerebral malaria, and no study has examined the impact of human immunodeficiency virus (HIV) infection. We examined the prevalence and etiology of bacteremia and the impact of HIV infection on bacteremia in Malawian children with severe malaria, as well as the impact of bacteremia and HIV infection on outcome. METHODS: From 1996 until 2005, blood for culture was obtained on admission from all children admitted with severe malaria during the rainy season to the Paediatric Research Ward at the Queen Elizabeth Central Hospital in Blantyre, Malawi. HIV testing was performed prospectively from 2001 to 2005 and retrospectively for those admitted from 1996 to 2000. Multivariate regression analysis examined independent risk factors for bacteremia and death. RESULTS: Sixty-four (4.6%) of 1388 children with severe malaria had bacteremia; nontyphoidal Salmonellae (NTS) accounted for 58% of all bacteremias. The prevalence of any bacteremia and of NTS bacteremia was highest in children with severe malarial anemia (11.7% and 7.6%), compared with the prevalence in children with cerebral malaria and severe anemia (4.7% and 3.8%) and in those with cerebral malaria alone (3.0% and 0.9%). HIV infection status was determined in 1119 patients. HIV prevalence was 16% (and was highest in those with severe malaria anemia, at 20.4%), but HIV infection was not significantly associated with bacteremia. Neither bacteremia nor HIV infection was associated with death. CONCLUSIONS: Antibiotics are not routinely indicated for children with severe malaria in this region, in which HIV is endemic. However, antibiotic therapy should be used to treat NTS infection if bacteremia is suspected in children with severe malarial anemia.     

Causes and outcome of bacterial meningitis in Malawian children

598 children with bacterial meningitis were admitted to the paediatric wards of the Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi from July 1997 – March 2001. Patients were followed up at 1 and 6 months after hospital discharge when physical, neurological, developmental and hearing assessments were made. The most common causes of pyogenic meningitis were Streptococcus pneumoniae (40%), Haemophilus influenzae type b (28%), Neisseria meningitidis (11%), Salmonella species (5%). There was no growth on culture in 13% of cases. The overall mortality was 31% and 38% were left with significant sequelae. Indicators for a poor prognosis were younger age, lower coma score on admission, bacterial cause, nutritional status and HIV positivity.     

Efficacy of a multi-micronutrient dietary intervention based on haemoglobin,hair zinc concentrations,and selected functional outcomes in rural Malawian children

OBJECTIVE: To investigate the efficacy of enhancing the content and bioavailability of micronutrients in diets of stunted rural Malawian children on their growth and body composition, morbidity, anaemia and hair zinc concentrations. DESIGN: A quasi-experimental design with non-equivalent control group involving 410 intervention and 220 control children aged 30-90 months. SETTING AND SUBJECTS: Children from two intervention and two control villages in Mangochi District, Southern Malawi participated in a 6 month dietary intervention. Anthropometry, malarial screening, haemoglobin, and hair zinc were measured at baseline and after 12 months, as well as socio-economic status at baseline, and common infections monthly post-intervention. RESULTS: Groups were comparable at baseline. Post-intervention children had greater Z-scores for lean body mass (mid-upper arm circumference -0.75 vs -1.05; arm muscle area: 0.63 vs -1.03, P<0.001) than controls but Z-scores for weight-for-height and height-for-age were similar. After controlling for baseline variables, mean haemoglobin was higher (107 vs 102 g/l, P<0.01), whereas the incidence of both anaemia (62 vs 80%) and common infections (based on a median overall illness score for fever, diarrhoea, upper and lower respiratory infections) were lower in intervention compared to controls, with no change in hair zinc concentrations or malaria status post-intervention. CONCLUSION: Improvements in the micronutrient adequacy of diets of post-intervention children were associated with a favourable increase in indices of lean body mass and reductions in the incidence of anaemia and common infections in these rural Malawian stunted children.     

Correlation of retinal haemorrhages with brain haemorrhages in children dying of cerebral malaria in Malawi

Retinal haemorrhages increase in number with severity of Plasmodium falciparum malaria and occur in 35-40% of children with cerebral malaria. We performed clinical retinal examinations and histopathological examinations of retina, and parietal and cerebellar sections of the brains, in 33 children in Malawi who died with cerebral malaria, severe malaria anaemia, or coma of other causes. Haemorrhages were counted in a standardized fashion: the Spearman correlation coefficient between the number of haemorrhages in retina and brain was 0.741 for parietal tissue and 0.703 for cerebellar (P < 0.01 for both). Severity of haemorrhage in the retina correlates well with that in the brain. Retinal examination in cerebral malaria is a useful tool in predicting some of the pathophysiological processes occurring in the brain.     

Changes in optic nerve head blood flow in children with cerebral malaria and acute papilloedema

Objective

To investigate capillary blood flow in the optic nerve head (ONH) of children with cerebral malaria.

Methods

Malawian children with cerebral malaria admitted to a paediatric research ward were examined by direct and indirect ophthalmoscopy. ONH blood flow was measured using laser Doppler flowmetry (LDF) in suitable patients. Mean blood volume and velocity were obtained from 30 to 60 s recordings from the temporal ONH and used to calculate blood flow. These were compared with admission variables, funduscopic findings and disease outcomes.

Results

45 children with cerebral malaria had LDF recordings; 6 subsequently died and 5 survivors had neurological sequelae. 12 (27%) had papilloedema. The mean microvascular blood volume was higher in patients with papilloedema (3.28 v 2.54 arbitrary units, p = 0.002). The blood velocity correlated directly with haematocrit (r = 0.46, p = 0.001) and inversely with blood glucose (r = −0.49, p = 0.001).

Conclusion

The increase in ONH microvascular blood volume in papilloedema measured by LDF is consistent with current theories of pathogenesis of papilloedema. LDF has potential as a tool to distinguish papilloedema from pseudopapilloedematous disc swellings. The relationship between blood velocity and haematocrit may relate to levels of sequestration in cerebral malaria.Cerebral malaria, caused by Plasmodium falciparum, primarily affects children in sub‐Saharan Africa with mortality ranging from 15% to 50%. The characteristic histological feature of malaria caused by P falciparum is sequestration of parasitised erythrocytes within the microvasculature by cytoadherence. This occurs in the brain^1,2,3 and other organs, including the retina.⁴ Sequestration in small vessels is implicated in the pathogenesis of coma in cerebral malaria, although the mechanism remains unclear.⁵Papilloedema occurs in 10–15% of patients with cerebral malaria, increasing the risk of death by 4.5‐fold.^6,7 Other ocular fundus features associated with cerebral malaria are retinal whitening, orange or white vessels, and retinal haemorrhage.^6,7,8,9 As in other neurological conditions, papilloedema is associated with raised intracranial pressure.⁵ The pathogenesis of papilloedema is associated with increased pressure within the optic nerve sheath, a compartment in contact with the subarachnoid space. This leads to interruption of axoplasmic flow in the optic nerve fibres, resulting in swelling of their prelaminar portion.^10,11 The exact mechanism of this restriction and the importance of vascular changes remain unclear.¹²The optic nerve head (ONH) is an accessible element of the central nervous system (CNS), and measuring blood flow in the ONH could illuminate the pathogenic mechanisms in cerebral malaria. Laser Doppler flowmetry (LDF) is a non‐invasive method of measuring blood flow in the ONH using the Doppler shift in laser light scattered by moving erythrocytes. By directing the laser away from visible blood vessels the microcirculation can be sampled. The mean relative blood velocity and volume are computed from the spectrum of Doppler frequency shifts. The volume is derived from the width of the Doppler shift spectrum, and the velocity from the magnitude of Doppler shifts. LDF has proved useful in physiological studies of ONH blood flow^13,14,15,16 and of glaucoma.¹⁷ A feasibility study of LDF in cerebral malaria produced promising results.¹⁸We report a study of ONH microcirculation in children with cerebral malaria in relation to clinical parameters, particularly papilloedema.     

'I don't want all my babies to go to the grave': perceptions of preterm birth in Southern Malawi

OBJECTIVE: to investigate perceptions of preterm birth, infections in pregnancy and perinatal mortality among women, men and health-care providers in Namitambo, Southern Malawi. DESIGN: a qualitative study using focus-group discussions, critical incidence narrative and key informant interviews. The framework approach to qualitative analysis was used. SETTING: Namitambo, a rural area in southern Malawi. PARTICIPANTS: women who have experienced preterm delivery, groups of mothers, fathers and grandmothers, health-care providers, traditional birth attendants and healers. FINDINGS: four key inter-related themes grounded in community interpretative frameworks emerged: (1) community conceptualisations of preterm birth (the different terminologies used); (2) perceived causes of preterm birth (i.e. both 'modern' and 'traditional; illnesses, violence, witchcraft, ideas relating to impurity, heavy work, inadequate food and inappropriate use of medicine); (3) perceived strategies to prevent preterm birth (i.e. using formal health services, treatment for sexually transmitted infections, using condoms and stopping violence); and (4) barriers to realising these strategies, such as lack of food, money and women's autonomy in health seeking. KEY CONCLUSIONS: similarities and differences exist in understanding between healthcare providers and the community. Additional dialogue and action is needed within the health sector and community to address the problem of preterm births. This includes strategies to enable health-care providers and community members to reflect on their perceptions and practices (e.g. through action research and interactive drama); identify and build on areas of common concern (i.e. poor pregnancy outcome) and enter into partnerships with non-formal providers. Action is also needed beyond the health sector (e.g. in campaigns to reduce gender-based violence).