Communities of practice
Cerebral Malaria in Children Is Associated With Long-term Cognitive Impairment
27 Aug 2008
Maria Victoria Valero
Source: Pediatrics
(see original article
)
Citation: John CC, Bangirana P, Byarugaba J, Opoka RO, Idro R, Jurek AM, Wu B, Boivin MJ (2008). Cerebral malaria in children is associated with long-term cognitive impairment. Pediatrics; 22(1):e92-99.
Cerebral malaria (CM) affects more than 785,000 children under nine years old in sub-Saharan Africa every year (1). Bovin et al. previously documented an increased frequency of cognitive impairment in children with cerebral malaria six months after their initial malaria episode (2). Unfortunately, few long-term prospective studies of cognitive function after CM have been performed. This kind of epidemiological study requires controlling the effects of confounding variables such as home environment, level of education or nutrition status. These variables are strongly associated with malaria severity and cognitive development and must be considered in the design and final analysis of studies.
The study by Dr Chandy John (a prestigious professor at University of Minnesota Medical School, Department of Pediatrics) and colleagues was designed to determine the long-term effects of cerebral malaria on the cognitive function of children with CM, compared with children with uncomplicated malaria (UC) and community children (CC). The added value of this study, compared with others previously published, is that it documents how deficits found early persist long-term, the study having taken place as a 24-month follow-up.
The investigation was conducted in children from 5 to 12 years of age in Mulago Hospital, Kampala, Uganda. Three groups of participants were enrolled in this prospective cohort study: (i) cerebral malaria (n = 44), (ii) uncomplicated malaria (n = 54), and (iii) healthy, asymptomatic community children (n = 89). Cognitive testing was performed at enrolment and two years later. The primary outcome was presence of a deficit in one or more of three cognitive areas tested (working memory, attention and tactile based-learning).
The authors present baseline characteristics, cognitive and neurological impairment at 24 months of follow-up, and clinical factors and cognitive deficits in children with CM.
At two-year follow-up testing, 26.3% of children with cerebral malaria and 12.5% with uncomplicated malaria had cognitive deficits in one or more areas, as compared with 7.6% of community children. Deficits in children with cerebral malaria were primarily in the area of attention (cerebral malaria, 18.4%, vs community children, 2.5%). After adjustment for age, gender, nutrition, home environment and school level, children with cerebral malaria had a 3.67-fold increased risk for a cognitive deficit compared with community children. Cognitive impairment at two-year follow-up was associated with hyporeflexia on admission and neurological deficits three months after discharge.
A considerable attention deficit can be attributed to malaria and level of severity in this poor and endemic region. Unfortunately, there are few strategies available to reduce the risk of malaria in such an environment.
As the authors mention, additional efforts must focus on elucidating the biological and neurological mechanisms of Plasmodium and its cerebral damage. Here we see two main challenges. Firstly, there is an urgent need to understand how the white matter deteriorates as a result of CM, as well as the specific brain areas closely related to cognitive deficit conditions. Secondly new information will contribute to overcoming the enormous challenges facing policy makers, health workers, patients and communities.
Nevertheless, the fight is not lost; the same authors published in 2006 an interesting discussion (3) of the strategic options in the field of cognitive rehabilitation for children. They highlight potential cognitive rehabilitation solutions such as cognitive exercises, environmental enrichment, nutritional supplementation, physical therapy and speech therapy. The barriers to be overcome in implementing such interventions are the limited human resources and infrastructure of the developing countries that are endemic for malaria.
The current course of malaria biology cannot be changed abruptly but research in the areas of public health, rehabilitation and neurology can contribute towards improving the quality of life of these young and vulnerable groups.
References
1. Murphy SC, Breman JG (2001). Gaps in the childhood malaria burden in Africa: cerebral malaria, neurological sequelae, anemia, respiratory distress, hypoglycemia, and complications of pregnancy. Am J Trop Med Hyg; 64 (1–2 suppl):57-67. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11425178
2. Boivin MJ, Bangirana P, Byarugaba J et al. (2007). Cognitive impairment after cerebral malaria in children: a prospective study. Pediatrics; 119 (2): e360-366. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17224457
3. Bangirana P, Idro R, John CC, Boivin MJ (2006). Rehabilitation for cognitive impairments after cerebral malaria in African children: strategies and limitations. Trop Med Int Health; 11(9):1341-1349. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16930255
Note: This article is published in a journal which is not open access. To see the full article a subscription to Pediatrics is therefore required. In some developing countries, readers who are based in institutions may be able to access it through the HINARI programme.
2008 by the American Academy of Pediatrics
Source
Related Articles
Comments
Featured Meetings:
Is your organisation working against the infectious diseases of poverty?
There are no comments about this article: Please login if you want to submit a comment.