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Background: Without interventions, the risk of mother-to-child transmission of HIV is 25% during pregnancy, labour and delivery with an additional risk of 5-20% during the breastfeeding, leading to an overall risk of 45%. The effectiveness of interventions towards prevention of mother-to-child transmission of HIV in any setting is measured by its HIV-free survival rate. We carried out a study to determine the HIV-free survival among breastfed infants enrolled by 2 months of age in a resource-poor setting. Methods: We conducted a cross-sectional survey of early infant diagnosis registers at two tertiary facilities in northern Uganda and retrospectively reviewed records of exposed infants enrolled from 2014 to 2016. We used simple random sampling and analyzed data using SPSS v16 software package. The chi-square and Student t-tests were used to compare factors among HIV-free survivors (HIV-uninfected and alive at 18 months) and those who became HIV-infected or died. Multivariate analysis using logistic regression was used to determine the factors that were independently associated with HIV-free survival. Odds ratios with 95% confidence interval were used to measure the strength of association between the outcome and predictor variables. P-value Results: The mean age at enrolment of the 317 infants was 1.57 (SD 0.23), majority of whom were males 55.5% (176/317). All except two infants were initiated on Nevirapine prophylaxis. Less than one third, 29.3% (93/317) of the infants were exclusively breastfed for at least 6 months, while the breastfeeding status of 30 infants could not be ascertained. The overall HIV-free survival rate in the current study was 94.6% (300/317), while 2.5% (8/317) were HIV-infected and 2.8% (9/317) died. Gender and treatment facility were the factors independently significantly associated with HIV-free survival. Conclusions: Our study estimates that the HIV-free survival rate in the study setting for breastfed infants enrolled by 2 months of age was 94.6%, below the WHO goal of >95% HIV-free rate in breastfeeding population for virtual elimination of HIV. A further prospective study would be necessary to assess a more accurate HIV-free survival rate given the limitations of retrospective data.

Southall made several points about our recent article.1 2 He suggests that “lethal hyperchloraemia” secondary to use of normal saline in FEAST (for boluses or maintenance) resulted in excess mortality. However, he did not comment on the key finding of the trial—that the increased 48 hour mortality was identical in both normal saline bolus (10.6%) and albumin bolus (10.6%) arms compared with the no bolus control group (7.3%).3 Harm was shown for every age group, in every condition, at each …

Methods We randomly assigned children with severe febrile illness and impaired perfusion to receive boluses of 20 to 40 ml of 5% albumin solution (albumin-bolus group) or 0.9% saline solution (saline-bolus group) per kilogram of body weight or no bolus (control group) at the time of admission to a hospital in Uganda, Kenya, or Tanzania (stratum A); children with severe hypotension were randomly assigned to one of the bolus groups only (stratum B). All children received appropriate antimicrobial treatment, intravenous maintenance fluids, and supportive care, according to guidelines. Children with malnutrition or gastroenteritis were excluded. The primary end point was 48-hour mortality; secondary end points included pulmonary edema, increased intracranial pressure, and mortality or neurologic sequelae at 4 weeks. Results The data and safety monitoring committee recommended halting recruitment after 3141 of the projected 3600 children in stratum A were enrolled. Malaria status (57% overall) and clinical severity were similar across groups. The 48-hour mortality was 10.6% (111 of 1050 children), 10.5% (110 of 1047 children), and 7.3% (76 of 1044 children) in the albumin-bolus, saline-bolus, and control groups, respectively (relative risk for saline bolus vs. control, 1.44; 95% confidence interval [CI], 1.09 to 1.90; P = 0.01; relative risk for albumin bolus vs. saline bolus, 1.01; 95% CI, 0.78 to 1.29; P = 0.96; and relative risk for any bolus vs. control, 1.45; 95% CI, 1.13 to 1.86; P = 0.003). The 4-week mortality was 12.2%, 12.0%, and 8.7% in the three groups, respectively (P = 0.004 for the comparison of bolus with control). Neurologic sequelae occurred in 2.2%, 1.9%, and 2.0% of the children in the respective groups (P = 0.92), and pulmonary edema or increased intracranial pressure occurred in 2.6%, 2.2%, and 1.7% (P = 0.17), respectively. In stratum B, 69% of the children (9 of 13) in the albuminbolus group and 56% (9 of 16) in the saline-bolus group died (P = 0.45). The results were consistent across centers and across subgroups according to the severity of shock and status with respect to malaria, coma, sepsis, acidosis, and severe anemia. Conclusions Fluid boluses significantly increased 48-hour mortality in critically ill children with impaired perfusion in these resource-limited settings in Africa. (Funded by the Medical Research Council, United Kingdom; FEAST Current Controlled Trials number, ISRCTN69856593.)

The 2013 World Health Organization guidelines continue to recommend rapid fluid resuscitation for children with shock despite evidence that this can be harmful. Sarah Kiguli and colleagues call for WHO to think again

Early rapid fluid resuscitation (boluses) in African children with severe febrileillnesses increases the 48-hour mortality by 3.3% compared with controls (nobolus). We explored the effect of boluses on 48-hour all-cause mortality byclinical presentation at enrolment, hemodynamic changes over the first hour, andon different modes of death, according to terminal clinical events. We hypothesizethat boluses may cause excess deaths from neurological or respiratory eventsrelating to fluid overload. Pre-defined presentation syndromes (PS; severe acidosis or severe shock,respiratory, neurological) and predominant terminal clinical events(cardiovascular collapse, respiratory, neurological) were described by randomizedarm (bolus versus control) in 3,141 severely ill febrile children with shockenrolled in the Fluid Expansion as Supportive Therapy (FEAST) trial. Landmarkanalyses were used to compare early mortality in treatment groups, conditional onchanges in shock and hypoxia parameters. Competing risks methods were used toestimate cumulative incidence curves and sub-hazard ratios to compare treatmentgroups in terms of terminal clinical events. Of 2,396 out of 3,141 (76%) classifiable participants, 1,647 (69%) had a severemetabolic acidosis or severe shock PS, 625 (26%) had a respiratory PS and 976(41%) had a neurological PS, either alone or in combination. Mortality wasgreatest among children fulfilling criteria for all three PS (28% bolus, 21%control) and lowest for lone respiratory (2% bolus, 5% control) or neurological(3% bolus, 0% control) presentations. Excess mortality in bolus arms versuscontrol was apparent for all three PS, including all their component features. Byone hour, shock had resolved (responders) more frequently in bolus versus controlgroups (43% versus 32%, P

BACKGROUND: Severe malnutrition contributes to more than 60 % of deaths in children in developing countries. The minimum international standard set for management of severe acute malnutrition is a cure rate of at least 75 % and death rate of less than 10 %, yet the outcome of severely malnourished children treated in most hospitals in developing countries remain poor. This study was conducted to determine the treatment outcomes among severely malnourished children admitted at St. Mary's hospital Lacor in Northern Uganda during a one year period in order to inform clinical decisions to maximize management of severely malnourished children. METHODS: This was a retrospective study involving 251 severely malnourished children treated at St. Mary's hospital Lacor within a one year period in 2014. Patients' medical records in the facility therapeutic feeding unit were retrospectively reviewed using a check list to collect basic demographic, clinical, and treatment outcome data of the sampled study patients. The UNICEF treatment outcome categories were used, and further grouped into three summary categories: "successful (cured)", "died" and "potentially unsatisfactory". Data were entered, cleaned and analyzed using statistical package SPSS version 13. For categorical data, proportions with 95 % confidence intervals, odds ratio and Chi-square test to compare different groups were used. Multivariate analysis using logistic regression was used to analyze the association between treatment outcome and potential associated factors. P values less than 0.05 was considered for statistical significance. RESULTS: The study consisted 251 patients and the treatment outcome was successful (cured) in 168 (66.9 %) and potentially unsatisfactory in 53 (21.2 %), while 30 (11.9 %) died. Hypothermia and HIV infection were the factors significantly associated with mortality among the severely malnourished children in the current study. CONCLUSIONS: The treatment cure rate of severely malnourished children admitted at St. Mary's hospital Lacor of 66.9 % is below the accepted standard of least 75 % cure rate. A high proportion of patients died (11.9 %) or defaulted (8.0 %). Hypothermia and HIV infection were the factors significantly associated with mortality. We recommend that in order to address the high default rate, home based care through the outpatient therapeutic care should be strengthened.

Background Lactose intolerance is a common complication of diarrhoea in infants with malnutrition and a cause of treatment failure. A combination of nutritional injury and infectious insults in severe protein energy malnutrition reduces the capacity of the intestinal mucosa to produce lactase enzyme necessary for the digestion of lactose. The standard management of severe malnutrition involves nutritional rehabilitation with lactose-based high energy formula milk. However, some of these children may be lactose intolerant, possibly contributing to the high rate of unfavorable treatment outcomes. This study was therefore designed to establish the prevalence of lactose intolerance and associated factors in this population. Methods A descriptive cross sectional study involving 196 severely malnourished children with diarrhoea aged 3-60 months was done in Mwanamugimu Nutrition Unit (MNU), Mulago hospital between October 2006 and February 2007. Results During the study period, 196 severely malnourished children with diarrhoea were recruited, 50 (25.5%) of whom had evidence of lactose intolerance (stool reducing substance ≥ 1 + [0.5%] and stool pH < 5.5) and it occurred more commonly in children with kwashiorkor 27/75 (36.0%) than marasmic-kwashiorkor 6/25 (24.0%) and marasmus 17/96 (17.7%). Oedematous malnutrition (p = 0.032), perianal skin erosion (p = 0.044), high mean stool frequency (p = < 0.001) and having ≥2 diarrhoea episodes in the previous 3 months (p = 0.007) were the independent predictors of lactose intolerance. Other factors that were significantly associated with lactose intolerance on bi-variate analysis included: young age of 3-12 months; lack of up to-date immunization; persistent diarrhoea; vomiting; dehydration, and abdominal distension. Exclusive breastfeeding for less than 4 months and worsening of diarrhoea on initiation of therapeutic milk were the other factors. Conclusions The prevalence of lactose intolerance in this study setting of 25.5% is relatively high. Routine screening by stool pH and reducing substances should be performed especially in the severely malnourished children with diarrhoea presenting with oedematous malnutrition, perianal skin erosion, higher mean stool frequency and having had ≥2 diarrhoea episodes in the previous 3 months. Use of lactose-free diets such as yoghurt should be considered for children found to have evidence of lactose intolerance and whose response on standard therapeutic milk formula is poor.

Background According to World Health Organization (WHO) estimates, 80 % of the population living in rural areas in developing countries depends on traditional medicine for their health needs, including use during pregnancy. Despite the fact that knowledge of potential side effects of many herbal medicines in pregnancy is limited and that some herbal products may be teratogenic, data on the extent of use of herbal medicines by women during pregnancy in the study setting is largely unknown. We determined the prevalence and factors associated with herbal medicine use during pregnancy among women attending postnatal clinics in Gulu district, Northern Uganda. Methods This was a descriptive cross-sectional study which involved 383 women attending postnatal care across four sites in Gulu district using quantitative and qualitative methods of data collection. A structured questionnaire was used to collect quantitative data while qualitative data were obtained using focus group discussions and key informant interviews. The selection of the study participants was by systematic sampling and the main outcome variable was the proportion of mothers who used herbal medicine. Quantitative data was coded and entered into a computerized database using Epidata 3.1. Analysis was done using Statistical Package for Social Scientists version 13, while thematic analysis was used for qualitative data. Results The prevalence of herbal medicines use during the current pregnancy was 20 % (78/383), and was commonly used in the second 23 % (18/78) and third 21 % (16/78) trimesters. The factors significantly associated with use of herbal medicines during pregnancy were perception (OR 2.18, CI 1.02-4.66), and having ever used herbal medicines during previous pregnancy (OR 2.51, CI 1.21-5.19) and for other reasons (OR 3.87, CI 1.46-10.25). Conclusions The use of herbal medicines during pregnancy among women in Gulu district is common, which may be an indicator for poor access to conventional western healthcare. Perception that herbal medicines are effective and having ever used herbal medicines during previous pregnancy were associated with use of herbal medicines during current pregnancy. This therefore calls for community sensitization drives on the dangers of indiscriminate use of herbal medicine in pregnancy, as well as integration of trained traditional herbalists and all those community persons who influence the process in addressing the varied health needs of pregnant women.