1. A MSF Newsletter of Paediatric Updates, Information, and Education The Khayelitsha Paediatric Report September, 2013 Volume 1, Number 2 Important Paediatric News from the National Department of Health (NDOH ) Molweni! New Data from the CHER Trial Teaching Corner The NDOH recently published the 2013 Antiretroviral Drug Dosing Chart for Children. The chart has been updated to include two newly registered drugs, both available on tender: 60mg ABC dispersible tablets and ABC (60mg) + 3TC (300mg) tablets. Below is a copy of the chart. A full size chart can be accessed through the SA Clinicians Society website: sahivsoc@sahivsoc.orgsahivsoc@sahivsoc.org A child's growth is one of the best indicators of a child’s health. Together with development, growth makes up the cornerstone of childhood health. Children's height and weight should be measured and plotted on the growth curves every time they are seen in the clinic. In addition, head circumference should be obtained for children under age 3. Some tips for obtaining accurate measurements are: For weight: Children should be weighed on the same scale for each visit. They should be minimally clothed. Do not let the child hold on to their parent while the measurement is being taken. (But obviously protect them from falling if needed). For length/height: For children <2 years old, measure length with the child supine on a flat, hard surface. The examination table is not ideal for this as it is too soft. Two people should do this measurement – one person holds the head and the other person the feet. For older children, do a standing height. The child should have his feet together with heels, buttocks and shoulder blades touching the vertical measure. The head should be in the Frankfurt plane (basically looking straight ahead). For head circumference: Measure midway between the eyebrows and the hairline at the front of the head and the occipital prominence at the back. Use a plastic measuring tape. Don’t forget to plot these measurements. Remember – a child's main “job” is to grow. Any “flat line” in growth or decrease in growth that crosses more than 2 percentile lines is a red flag and requires investigation to find a cause! One of the landmark paediatric HIV studies of this century (and really of all time) has been the CHER trial, completed by Dr. Marc Cotton and his team at Stellenbosch University. Data from this study showed that early treatment with ARVs in infants decreased mortality. South African and WHO guidelines regarding when to start children on ARVs is based largely on the findings from this trial. Last week, the Lancet published more findings from the study. The new data strengthens its earlier findings that early treatment decreases mortality for children. In this latest study, three groups of patients were compared: infants who were deferred ARV treatment, infants who were started immediately on ARVs and stayed on them for 40 weeks, and infants who were started immediately on ARVs and stayed on them for 96 weeks. After their time on ARVs, the latter 2 groups had their treatment interrupted. They monitored all three groups and had clinical and immunological criteria for when to restart the infants. What they found was that not only does early initiation of ART in infants decrease overall mortality, but those who were started early and had treatment interrupted still did better clinically and immunologically than those who had ART deferred. Note: While early initiation is obviously a great idea (and has been embraced by the NDOH), the concept of treatment interruption is more controversial and is currently not part of SA guidelines. In fact, there are very good arguments against doing this. Treatment interruption was used as part of this study, and although the results showed better outcomes than deferring ART, it should not be employed as standard of care for paediatric HIV patients at this time. Important Paediatric Advocacy Messages! This month, we provide additional news from the NDOH, as well as important information from the CHER trial. We also start a new section on paediatric advocacy. And don't forget the "Teaching Corner" for your source of continuing paediatric education. Enjoy! Each month, space will be set aside in this newsletter to discuss issues related to paediatric advocacy. Paediatric HIV: A Neglected Disease Did you know that paediatric HIV is considered a neglected disease by many organizations such as MSF, DNDi, and others? While PMTCT has had a dramatic effect on decreasing the amount of HIV-positive children worldwide, children that do become HIV positive are not receiving all the help they deserve. For example, pharmaceutical companies have been very slow to develop paediatric formulations of drugs that have been available for adults for years. As the market is smaller for children, developing paediatric dosages and formulations is not lucrative for them. Hence, they do not do the research necessary to get these drugs to children. Drug formulations such as FDC’s (fixed drug combinations) and more palatable formulations (such as sprinkles and granules) would make a big difference in our success rates in paediatric HIV. It is up to all of us to urge drug companies to develop these drugs! Shortage of Paediatric Testing Only 28% of the world's children who qualify for ARV treatment are receiving it. Only 28%!!! And in 25 African countries, the rate is less than 25%! Furthermore, this percentage does not even include those children who have not been tested for HIV. The first step in getting children into care is to have them tested. Here are some of things you can do to increase the testing rate in children in your clinic: -Whenever you see a child in clinic, always ask if there are other children in the home and if they have been tested. If they have not, make an appointment for them to come in. -If a sibling is present in clinic, ask about their HIV status. If there status is unknown, offer to have them tested that same day. If they cannot stay for the test that day, make an appointment for them to come back. -Work with your clinic to set up a paediatric testing area and to up skill current staff on how to test children for HIV.