New clinical guidelines from the American Academy of Pediatrics (AAP) advise “immediate, intensive obesity treatment to each patient” upon diagnosis of childhood obesity. Published in the journal Pediatrics, these recommendations stands in marked contrast from other, previous guidelines.
The guidelines are summarised in key action statements, some of which recommend children ages 6 and up (and sometimes 2 to 5) with overweight or obesity to intensive health behaviour and lifestyle therapy.
In children 12 and older, the guidelines advise consideration of weight-loss pharmacotherapy. In case of severe obesity (BMI ≥35 or 120% of the 95th percentile for age and sex, whichever is lower) for adolescents 13 and older, clinicians should offer referrals for evaluation for metabolic and bariatric surgery.
Author Sarah Armstrong, MD, co-director of the Duke Center for Childhood Obesity Research told Medpage Today that “This is one of the most important messages that differentiates our current clinical practice guidelines from the prior recommendations, and that is to say 15 years of data have taught us that ‘watchful waiting’ only leads to greater increase in child BMI, accumulation of comorbidities, and more challenges in trying to reverse some of this.”
The guidelines also recommend regularly screening children ages 2 years and up for obesity, and comprehensively evaluating children and adolescents with overweight and obesity for related comorbidities.
Clinicians are also advised to treat children and adolescents for overweight/obesity and comorbidities concurrently, in line with principles of the chronic care model, using a non-stigmatising approach centred around the family.
The guidelines are based on a comprehensive evidence review of controlled and comparative effectiveness trials and high-quality longitudinal and epidemiologic studies. In a pair of accompanying technical reports, the authors give detailed descriptions of the evidence review behind the development of the guidelines.
An explanatory model presented in a thesis from University of Gothenburg may make simplify the understanding of autism development. It provides new insights into how various risk factors give rise to autism and why there is such great variability between individuals.
Autism, a neurodevelopmental condition, affects how people perceive the world around them and how they interact and communicate with others. Among individuals with autism, there are major differences in terms of personal traits and manifestations alike. The disorder is therefore usually described as a spectrum, with numerous subtle variations.
While theoretical, the new explanatory model is also practical in application, since its various components are quantifiable through testing. The model describes various contributing factors and how they combine to prompt an autism diagnosis and cause other neurodevelopmental conditions.
Three contributing factors
The model links three contributing factors. Together, these result in a pattern of behaviour that meets the criteria for an autism diagnosis:
Autistic personality – hereditary common genetic variants that give rise to an autistic personality.
Cognitive compensation – intelligence and executive functions, such as the capacity to learn, understand others, and adapt to social interactions.
Exposure to risk factors – for example, harmful genetic variants, infections, and other random events during gestation and early childhood that adversely affect cognitive ability.
“The autistic personality is associated with both strengths and difficulties in cognition but does not, as such, mean that diagnostic criteria are fulfilled. Still, exposure to risk factors that inhibit people’s cognitive ability may affect their capacity to tackle difficulties, which contributes to individuals being diagnosed with autism,” says Darko Sarovic, physician and postdoctoral researcher at Sahlgrenska Academy, University of Gothenburg, who wrote the thesis.
The model makes it clear that it is the many different risk factors combined that bring about the major differences among individuals on the spectrum. The various components of the model are supported by results from previous research.
Adaptive ability
High executive functioning skills may let people cover up their impairment, reducing their risk of meeting the diagnostic criteria for autism. This may explain why a lower degree of intelligence is observed among people diagnosed with autism, as well as other neurodevelopmental conditions. It also affords an understanding of why intellectual disability is more common among these groups. Thus, the model indicates that low cognitive ability is not part of the autistic personality but, rather, a risk factor that leads to diagnostic criteria being met.
“The autistic personality is associated with various strengths. For example, parents of children with autism are overrepresented among engineers and mathematicians. The parents themselves have probably been able to compensate for their own autistic personality traits and thus not met the criteria for an autism diagnosis. The impact of the disorder has then become more noticeable in their children owing, for instance, to an exposure to risk factors and relatively low cognitive ability,” Sarovic says.
Gender differences affect diagnosis
The diagnosis of autism is more common among boys than girls, and girls often get their diagnosis later in life. Some girls reach adulthood before being diagnosed, after many years of diffuse personal difficulties.
“Girls’ symptoms are often less evident to other people. It’s well known that girls generally have more advanced social skills, which probably means that they’re better at compensating for their own difficulties. Girls also tend to have fewer autistic traits and be less susceptible to the effects of risk factors. Accordingly, the model can help to answer questions about the gender gap,” Sarovic says.
Research and diagnostics
The model also proposes ways of estimating and measuring the three factors, enabling use of the model in research studies. Diagnostics is another conceivable area of use. In a pilot study in which 24 participants had been diagnosed with autism and 22 controls had not, measuring the three factors of the model enabled more than 93% to be correctly assigned to the right category. The model can also be used to explain the inception of other neurodevelopmental disorders, such as schizophrenia.
Analysing magnetic resonance imaging (MRI) brain scans of nearly 2000 children, researchers found children who played video games for three or more hours a day did better in cognitive skills tests involving impulse control and working memory compared to children who had never played video games. Published in JAMA Network Open, this study analysed data from the ongoing Adolescent Brain Cognitive Development (ABCD) Study, which is supported by the and other entities of the National Institutes of Health.
“This study adds to our growing understanding of the associations between playing video games and brain development,” said National Institute on Drug Abuse (NIDA) Director Nora Volkow, MD. “Numerous studies have linked video gaming to behaviour and mental health problems. This study suggests that there may also be cognitive benefits associated with this popular pastime, which are worthy of further investigation.”
Although a number of studies have investigated the relationship between video gaming and cognitive behaviour, the neurobiological mechanisms underlying the associations are not well understood. Only a handful of neuroimaging studies have addressed this topic, and the sample sizes for those studies have been small, with fewer than 80 participants.
To address this research gap, scientists at the University of Vermont, Burlington, analysed data obtained when children entered the ABCD Study at ages 9 and 10 years old. The research team examined survey, cognitive, and brain imaging data from nearly 2000 participants from within the bigger study cohort, comparing those who reported playing no video games at all and those who reported playing video games for three hours per day or more. This threshold was selected as it exceeds the American Academy of Paediatrics screen time guidelines, which recommend limiting videogames to one to two hours per day for older children. Researchers assessed their performance in two tasks that reflected the children’s ability to control impulsive behaviour and to memorise information, as well as brain activity while performing the tasks.
The researchers found that the children who reported playing video games for three or more hours per day were faster and more accurate on both cognitive tasks than those who never played. They also observed that the differences in cognitive function observed between the two groups was accompanied by differences in brain activity. Functional MRI brain scans found that children who played video games for three or more hours per day showed higher brain activity in regions of the brain associated with attention and memory than in never-gamers. At the same time, those children who played at least three hours of videogames per day showed more brain activity in frontal brain regions that are associated with more cognitively demanding tasks and less brain activity in brain regions related to vision.
The researchers think these patterns may stem from practicing tasks related to impulse control and memory while playing videogames, which can be cognitively demanding, and that these changes may lead to improved performance on related tasks. Furthermore, the comparatively low activity in visual areas among children who reported playing video games may reflect that this area of the brain may become more efficient at visual processing as a result of repeated practice through video games.
While prior studies have reported associations between video gaming and increases in depression, violence, and aggressive behaviour, this study did not find that to be the case. The three hours or more group tended to report higher mental health and behavioural issues compared to the non-gaming children, but was not statistically significant. The researchers note that this will be an important measure to continue to track and understand as the children mature.
Further, the researchers stress that this cross-sectional study does not allow for cause-and-effect analyses, and that it could be that children who are good at these types of cognitive tasks may choose to play video games. The authors also emphasise that their findings do not mean that children should spend unlimited time on their computers, mobile phones, or TVs, and that the outcomes likely depend largely on the specific activities children engage in. For instance, they hypothesise that the specific genre of video games, such as action-adventure, puzzle solving, sports, or shooting games, may have different effects for neurocognitive development, and this level of specificity on the type of video game played was not assessed by the study.
“While we cannot say whether playing video games regularly caused superior neurocognitive performance, it is an encouraging finding, and one that we must continue to investigate in these children as they transition into adolescence and young adulthood,” said Bader Chaarani, PhD, assistant professor of psychiatry at the University of Vermont and the lead author on the study. “Many parents today are concerned about the effects of video games on their children’s health and development, and as these games continue to proliferate among young people, it is crucial that we better understand both the positive and negative impact that such games may have.”
Through the ABCD Study, researchers will be able to track these children into young adulthood, looking for gaming-related changes in cognitive skills, brain activity, behaviour, and mental health.
Giving three years of chemotherapy to children with acute lymphoblastic leukaemia (ALL) instead of two years lowers the risk of their disease coming back after treatment by three times. The survival rate of all children with ALL, the most common form of childhood cancer, together has further increased to 94%. Less intensive therapy proved safe for three groups of children, resulting in a better quality of life. These findings on a large Dutch study into ALL were reported at the annual conference of the American Society of Hematology (ASH).
Many children with ALL have good outcomes. After two years of chemotherapy treatment, nine out of ten children are cured. But some children have a more aggressive disease, such as having the Ikaros mutation in their leukaemia cells, have a greater risk of recurrence after treatment. In order to improve the chances of survival and quality of life of all children with leukaemia, the treatment protocol has been continuously adapted over the years, based on the latest scientific insights.
Prof Rob Pieters, medical director and paediatric oncologist at the Princess Máxima Center for paediatric oncology in the Netherlands, presented the outcomes of the ALL-11 treatment protocol. The Dutch researchers tested the benefit of an adapted treatment in specific groups of children with leukaemia, including children with the Ikaros mutation. More than 800 children in the Netherlands were treated with this protocol between April 2012 and July 2020.
Threefold lower risk of recurrence
Children with Ikaros leukaemia received an extra year of chemotherapy in the ‘maintenance phase’ on top of the first two years of treatment. This change lowered the risk of their cancer coming back by threefold: this happened in only 9% of them, compared to 26% of the children in the previous treatment protocol.
87% of children with Ikaros leukaemia survived their disease for five years without their cancer coming back, an improvement on the 72% in the previous protocol. Because of the extra year of chemotherapy, this group of children had a slightly higher risk of infection, but these were treatable. The extended therapy did not lead to any additional side effects.
Analysis of data from all children with ALL, regardless of subtype, showed that the five-year survival rate has improved stepwise over the past 30 years from 80% to 94% under the ALL-11 protocol.
Safe reduction of treatment
In the ALL-11 protocol, doctors and researchers also looked at the benefit of a less intensive treatment plan for three groups of children. This included children with a leukaemia mutation linked to a very high chance of recovery, and children with Down syndrome who experience more severe side effects. These children received treatment without or with a lower dose of anthracyclines, a type of leukaemia drug that increases the risk of heart damage and infections. The reduced treatment proved successful: children had the same or even a better chance of survival, while their quality of life improved due to a lower risk of infections and damage to the heart.
Global interest
Globally, there is much interest in the Dutch research as it has been unclear how to improve therapy for children with Ikaros leukaemia. The results have now been presented for the first time at the largest blood cancer conference, and could lead to changes in treatment protocols for these children worldwide.
In the Netherlands, there are about 15 children with ALL each year for whom existing treatments stop working. Since 2019, they have been eligible for treatment with CAR T-cell therapy, a promising form of immunotherapy that now leads to a cure in 40% of these children.
Making a difference
Prof Monique den Boer, medical biologist and group leader at the Princess Máxima Center, played an important role in the adapted therapy for children with the Ikaros gene change. She says: ‘The Ikaros mutation was first discovered about 15 years ago in children with leukaemia who had a poor prognosis, partly thanks to the emergence of new DNA technologies. We saw that the cancer came back in many of these children shortly after the end of the two-year treatment plan. I am very proud that our lab findings have now found their way into the clinic and can make such a big difference for children with leukaemia.”
More cure with fewer side effects
Prof Pieters concludes: The five-year survival rate for children with acute lymphoblastic leukaemia has increased enormously since the 1960s, from zero to 94%, but the last steps are the most difficult. We are now one step closer to curing all children with ALL. We have also largely been able to remove a drug that poses a risk of heart damage from the treatment of children with a less aggressive form of the disease. The latest results for children with leukaemia therefore fit in perfectly with our mission: curing more children with cancer, with fewer side effects.”
The presence of food-specific IgA antibodies in the gut does not prevent peanut or egg allergies from developing in children, according to a Northwestern Medicine study published in Science Translational Medicine.
Scientists examined stool samples from more than 500 infants across the country and found that the presence of Immunoglobulin A, the most common antibody found in mucous membranes in the digestive tract, does not prevent peanut or egg allergies from developing later in life.
This discovery calls into question the role of Immunoglobulin A, or IgA, which was previously thought to be a protective factor against the development of food allergies.
While prior research had shown IgA could bind to and neutralide toxins and bacteria in the body, there was inconclusive evidence that IgA could do the same for food allergens, said Stephanie Eisenbarth, MD, PhD, senior author of the study.
“We were able to collaborate with different groups around the country to look at a number of different cohorts of children and young adults to ask: ‘Does the presence of IgA to peanut tell us that the person is tolerant to peanut?’,” said Eisenbarth. “We found that there really was no difference between kids who had peanut allergies and children who didn’t, and the same is true with egg allergies.”
The findings come as rates of allergies in children continue to climb: According to data from the Centers for Disease Control and Prevention, the number of children with allergies has more than doubled in the last 20 years.
Future directions for research will center on understanding the role IgA plays in people who have undergone immunotherapy and developed a tolerance to food allergens, Eisenbarth said.
Atopic dermatitis (AD) is the most common, chronic, recurrent, inflammatory disorder of the skin, and it affects 5–30% of children worldwide. An analysis in the Journal of the European Academy of Dermatology & Venereologyof relevant published studies found that early application of emollients is an effective strategy for preventing AD in high-risk infants.
The analysis included 11 randomised controlled trials involving 3483 infants. Three types of emollients, including cream, emulsion, and mixed types were comparable in preventing AD; however, an additional analysis suggested that emollient emulsion may be the best option.
This analysis revealed a surface under the cumulative ranking curve (SUCRA) of 82.6%, 78.0% for high-risk infants and 79.2% for infants with food sensitisation. However, subjects receiving emollients more frequently experienced adverse events.
“The results of this systematic review and network meta-analysis show that early application of skin emollients can effectively prevent AD development in infants,” the authors wrote. “Moreover, among the available three types of emollients, the emollient emulsion is probably the optimal option in infancy to prevent AD development more effectively.”
“It was very, very critical to me. It was an albatross around my neck. It was something that caused a deep persistent anxiety in me…”
This is how a 61-year-old retired school teacher from a township on the East Rand describes the feelings he had around disclosing to his son that he (the child) was born with HIV.
The man, who taught life orientation skills and history, agreed to be interviewed on condition that their identities are protected.
Speaking to Spotlight he says, “With my son, it became late in his life because I didn’t know how to do it – how to tell him. So I postponed and postponed. It was becoming increasingly difficult.”
Three months after the boy was born in 2001 at the Far East Rand Hospital in Springs, the child’s mother passed away from an HIV-related illness. At the time, hospital staff referred the widowed father and baby boy to HIV and AIDS treatment non-profit organisation Right to Care where Dr Leon Levin diagnosed the child with HIV.
“My wife died three months after giving birth. I didn’t realise then that she had HIV and that I have HIV. I took my son to Dr Levin, who tested him. I started giving my son ARVs. I had to employ someone to look after the child while I was working, and this woman didn’t truly understand about adherence and at times did not give him all his medicine. So she defaulted, which is very bad. It was a time when not much information was available, the time of the president [Thabo Mbeki] denying that HIV causes AIDS.”
Also in 2001, young orphan Nkosi Johnson died of AIDS in Johannesburg at the age of 12. Johnson made headlines the previous year when he told the International AIDS Conference in Durban “care for us and accept us. We are all human beings”.
‘Taking medication as a team’
As the years went by, the man says, the burden in his heart grew bigger. “We would go to Dr Levin every six months for a check-up,” he says. “I would tell my son that he is sick, but I did not explain why.”
Eventually, the man felt comfortable allowing Levin to assist in sharing the news with his son. “Around the age of 16, Dr Levin did a full disclosure with my son. It was the heaviest weight off my shoulders. After that intervention, we could speak properly. We had a heart-to-heart, and we started taking medication as a team. This made it easy for me to explain to the child the advantages of adhering [to ARV treatment], the meaning of defaulting [failing to take ARV treatment regularly, as prescribed], and all these consequences. I could discuss with my son the importance of adherence because when you default, the medication becomes resistant. I told him if you take your medication, you can live a long life. You can get married and you can have children.”
Despite the substantial progress South Africa has made in fighting HIV over the last decade and a half, HIV in children is still quite common. According to the latest estimates from Thembisa – the leading mathematical model of HIV in South Africa – around 238 000 children (under the age of 15) were living with HIV in the country in 2021. There were just over 8 300 cases of mother-to-child transmission of HIV last year. While still a staggering problem, this is a significant improvement from the early 2000s when the number was around 74 000.
Disclosure – how to get it right
Sharing news of being born with HIV to a child (perinatal infection) is perhaps an often overlooked, deeply tender aspect of the country’s broader HIV response. The National Department of Health recommends “partial disclosure” from three years old and “full disclosure” from around 10 years old – ideally before a child is 13 or before their sexual debut.
Levin, who is based in Johannesburg, and Dr Julia Turner, who is based in White River, Mpumalanga – both are with Right to Care – spoke to Spotlight about how they assist parents and children in this regard.
“Parents are so scared to tell their child that they have HIV, so they delay and delay and delay,” says Turner. “If you ask a parent they’ll say, oh no, let’s wait until they’re 15. And then they say, oh no, let’s wait until they’re 18. Because it’s such a difficult thing for them to do. They’re scared that their child will be devastated and become depressed and blame them. So they delay and delay and eventually the child either googles it themselves or reads their own file while they’re waiting for the doctor at the clinic. Teenagers and children are generally much smarter than anyone ever thinks they are.”
Levin and Turner point out that it is unreasonable to expect a child or teenager to regularly take medicine when they don’t know what it is for.
“At some stage, the children will ask why do I need this?” says Turner. “Or they’re refusing to take it and then the parents don’t know what to say, so they end up making up something. So they’ll say, you’ve got TB, or you’ve got asthma, or you’ve got herpes, or they make up any excuse as to why the child must take treatment. Perhaps ‘you must take the treatment, otherwise, you’ll die’, which is a bit scary. None of these answers are satisfactory, plus the child might be angry later if they learn they were lied to.”
Levin has been treating children and adolescents with HIV for 26 years. When he started, there were no guidelines and he had to learn from his own mistakes.
“Leon has been a paediatrician for many years and he was dealing with children and teenagers,” says Turner. “And he had to just figure out a way to tell them. And initially, it ended in tears. The child was crying, the parents were crying, he was crying, everyone… So, he slowly developed this technique of doing it so that it was brought into a positive light. And that really worked.”
Turner has helped to refine the technique. They explain that partial disclosure is explaining to a child that they have to take their treatment – without telling the child untruths but without bringing up HIV. Full disclosure is naming the child’s condition as “HIV”.
“Unfortunately, schools use HIV for their own purposes,” says Levin. “They’re using it basically to encourage children not to be promiscuous. So they’re giving out the message that only bad people get HIV and that people die from HIV. So while this works to encourage children to not be promiscuous, the problem is that as soon as a child hears the word ‘HIV’ or that they’ve got HIV, they immediately think they’re going to die – there’s that bad connotation.”
The story of the ‘soldier cells’
Right to Care recommends providing the young child with full information about HIV, without actually naming the disease, to avoid stigma and fear. The crux of the method is to not use the word “HIV” until myths around HIV are dispelled. The organisation offers illustrated booklets, depicting their narrative where white blood cells are depicted as soldiers.
“So we basically tell them a little story that in their body they have white blood cells,” Turner explains. “We say white blood cells are like soldiers and they go around your body and they protect you from germs. But you weren’t born with enough soldiers in your body. So that’s why you can get sick very easily. But the tablets or the medicine you take can help to keep your soldiers strong, keep your immune system strong, and fight off all the germs. So at least that’s true, and it’s a good reason why they must take their medicine. And they are usually very satisfied with that.”
As the child gets older, the story is expanded.
“As they get older, we can say, okay, well, why don’t you have enough soldiers in your blood?” she says. “And then we tell them it’s because you have a virus. You were born with a virus that kills off your soldier cells. And then as they get older, eventually when they’re about 10 years old, you can then say do you want to know the name of that virus that you have? And that’s when we turn partial disclosure into full disclosure by telling them the name HIV.”
Questions and answers
News of the parent having HIV is shared in a similar manner by framing the virus in a positive light. No blame is placed on the parent ever. Instead, when speaking to the child about their HIV status, the doctors recommend that if any blame is apportioned, that it be on the medical fraternity “for not having better medicine available” at the time of the child’s birth.
“We ask the child what they know about HIV, just to try and find out what negative things they have been told,” says Turner. “Then we tell them no, it’s not true, actually, people with HIV live long and healthy lives… I always ask them, what they want to be when they grow up. And if they say they want to be a pilot or a doctor or a teacher, I say, do you think people with HIV can be a pilot? And they always say no. And then I say, of course, they can. People with HIV can do anything they want to do. They can be doctors, teachers, anything.”
Right to Care is set to bring out a disclosure flip chart to help healthcare workers and primary caregivers with this conversation, which might be rolled out by the health department nationally.
“The thing is, you have to think on your feet because you’re having a conversation with this young child and it’s not so straightforward. But the flip chart tells you exactly what to say, it makes it much easier,” says Levin.
Meanwhile, the retired teacher and his now 22-year-old son are together establishing a small business in their community.
“My advice to parents,” he says. “Sharing their HIV status with children might feel like a bombshell. They must ask for professional help – doctors have techniques to make it easier.”
A large-scale study published in JAMA Network has found no link between benzodiazepines use in pregnancy and subsequent autism spectrum disorder (ASD) or attention-deficit/hyperactivity disorder (ADHD) diagnoses in offspring. When comparing siblings, benzodiazepines use had no effect on ASD or ADHD risk, indicating that the mother’s genetics partly explained the increased risk.
Some 10–30% of pregnant women experience mental disorders, including mood or anxiety spectrum disorders, for which benzodiazepine agents are sometimes prescribed; this occurs in an estimated 1.9% of pregnancies globally.
The safety of these agents to the developing foetus and newborn has been called into question, since benzodiazepines are able to cross the placenta and have been found to be present in amniotic fluid and breast milk. The US FDA includes in the category of possible harm to the foetus.
While rodents studies have tested benzodiazepine exposure during the first trimester of pregnancy, investigations of neurodevelopmental outcomes in humans, such as ASD and ADHD, have been lacking.
One study found no significantly increased risks of ADHD symptoms or fine or greater motor deficits. Those researchers suggested the disorder resulting in benzodiazepine use might partly explain the increased risks. Maternal depressive and anxiety symptoms in pregnancy have also been linked to increased ADHD risk in children.
From the Taiwanese national health database, of over 1 .5 million children born full term who were younger than 14 years of age and followed up to 2017; 5.0% had been exposed to benzodiazepines in utero.
However, no differences were found with unexposed sibling controls during the same time frame for ADHD or ASD.
The researchers concluded that their results “challenge current assumptions of a potential association of neurodevelopmental disorders with maternal benzodiazepine use before or during pregnancy. Better identification of maternal mental health concerns, as well as possible interventions or provisions of guidance to build better nurturing and raising environments for newborns at risk, may be relevant to the prevention of adverse outcomes of neurodevelopmental disorders.”
WHO today launched new guidelines to improve survival and health outcomes for babies born preterm (< 37 weeks) or small (< 2.5kg). In a significant departure from common clinical practice, the guidelines advise that caregiver skin to skin contact with a caregiver – aka kangaroo mother care – should start immediately after birth, without incubator stabilisation. This reflects the immense health benefits of ensuring caregivers and their preterm babies can stay close, without being separated, after birth.
The guidelines also provide recommendations to ensure emotional, financial and workplace support for families of very small and preterm babies, who can face extraordinary stress and hardship because of intensive caregiving demands and anxieties around their babies’ health.
“Preterm babies can survive, thrive, and change the world – but each baby must be given that chance,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “These guidelines show that improving outcomes for these tiny babies is not always about providing the most high-tech solutions, but rather ensuring access to essential healthcare that is centred around the needs of families.”
Depending on where they are born, there remain significant disparities in a preterm baby’s chances of surviving. While most born at or after 28 weeks in high-income countries go on to survive, in poorer countries survival rates can be as low as 10%.
Most preterm babies can be saved through feasible, cost-effective measures including quality care before, during and after childbirth, prevention and management of common infections, and kangaroo mother care – combining skin to skin contact in a special sling or wrap for as many hours as possible with a primary caregiver, usually the mother, and exclusive breastfeeding.
Previous recommendations for preterm babies were for an initial period of separation from their primary caregiver, with 3–7 days of initial stabilisation in an incubator or warmer. However, research has now shown that starting kangaroo mother care immediately after birth reduces mortality, infections and hypothermia, and improves feeding.
Breastfeeding is also strongly recommended to improve health outcomes for preterm and low birthweight babies, with evidence showing it reduces infection risks compared to infant formula. Where mother’s milk is not available, donor human milk is the best alternative, though fortified ‘preterm formula’ may be used if there are no donor milk banks.
Integrating feedback from families gathered through over 200 studies, the guidelines also advocate for increased emotional and financial support for caregivers. Parental leave is needed to help families care for the infant, the guidelines state, while government and regulatory policies and entitlements should ensure families of preterm and low birthweight babies receive sufficient financial and workplace support.
Earlier this year, WHO released related recommendations on antenatal treatments for women with a high likelihood of a preterm birth. These include antenatal corticosteroids, which can prevent breathing difficulties and reduce health risks for preterm babies, as well as tocolytic treatments to delay labour and allow time for a course of corticosteroids to be completed. Together, these are the first updates to WHO’s preterm and low birth weight guidelines since 2015.
The guidelines were released ahead of World Prematurity Day, which is marked every year on 17th November.
Figure 1. The epidemiological curve of measles outbreak cases, Greater Sekhukhune and Mopani Districts, Limpopo province, September to November 2022 (*Two sporadic cases in Vhembe District are not included). Source: NICD
As of 10 November, the National Institute of Communicable Diseases reported 35 laboratory-confirmed measles cases in Limpopo, with 14 new cases on 8 and 9 November, all in Mopani district. Thus far, most of the laboratory-confirmed cases (25 of 35) fall within the 13 month to 9 year age range.
With these new cases, the Mopani district with 19 cases has overtaken the Greater Sekhukhune district which remains at 16 (see Figure 1). Only seven cases are known to be vaccinated; eight are either unvaccinated or partially vaccinated; vaccination status of the remaining 20 is unknown.
According to a recent study published in BMC Public Health, measles has been experiencing a resurgence in South Africa. Over 2015–16, measles had remained largely under the elimination target of under one case per million in South Africa, but rose above this threshold from 2017–2019. Cases fell below the threshold in 2020 with the onset of COVID, but the pandemic also saw normal vaccination efforts slipping. The article authors also noted a measles vaccine effectiveness of only 80% among 1–4 year olds, compared to the 95% rate found in large datasets.
Those cases reported in the Mopani district were in the Greater Giyani, Ba-Phalaborwa, and Ga-Kgapane sub-districts. Epidemiological investigations showed that in the Mopani district, two siblings with measles infection had contact with cases in the Greater Sekhukhune district when they travelled there for a family funeral.
While two cases were reported in Vhembe District, they were considered sporadic as they had not links to the other cases and are not included in the outbreak tally.
The laboratory-confirmed measles infections have been identified in 19 males and 16 females ranging in age from 6 months and 24 years in the Greater Sekhukhune district, while cases range from 2 to 42 years in the Mopani district (Table 1), with increasing cases in the 5–9 year age range. Two children were hospitalised but no deaths or other complications from measles have been reported.
According to the NICD, the affected districts are continuing with the public health response activities and tracing and vaccinating contacts. Measles catch-up doses are also being given to children who have missed vaccinations.
