BACKGROUND:Female genital mutilation (FGM) is recognized as a violation of human rights, with global prevalence affecting million girls and women. FGM varies in type and severity, and poses physical, emotional, and social risks, with a significant impact on female sexual function leading to mental health issues and reduced quality of life. Surgical techniques, such as clitoral reconstructive surgery, are practiced to restore clitoral function. OBJECTIVES:To assess the effectiveness of clitoral reconstructive surgery in mitigating sexual dysfunction, vulvodynia, clitoral pain, low self-esteem, and negative body image among women living with any type of FGM. SEARCH STRATEGY:The following major databases were searched for published and gray literature, without language restrictions, from inception to May 2023: CINAHL Plus, IRIS, MEDLINE (Ovid), PsycINFO (EBSCOhost), SCOPUS, and Web of Science. SELECTION CRITERIA:Controlled studies, cohort studies, and quasi-experimental studies with assessment before and after the intervention were included if they involved women seeking clitoral reconstruction to address the selected outcomes measured (sexual dysfunction, vulvodynia, clitoral pain, low self-esteem, and negative body image). DATA COLLECTION AND ANALYSIS:Studies were independently assessed for inclusion, data extraction, and risk of bias. Data were extracted for meta-analyses and the evidence assessed using the GRADE (Grade of Recommendation, Assessment, Development and Evaluation) approach. MAIN RESULTS:We identified 13 studies. All but one used the same "Foldès technique". The other study used a vaginal mucosal graft. Meta-analysis of vulval pain, clitoral pain, or pain during intercourse before and after clitoral reconstruction showed a significant reduction in pain (odds ratio 79.67, 95% confidence interval 41.67-152.33). The studies also reported an improvement in body image and self-esteem, as well as in clitoral sexual function. Adverse events included hematoma, infection, suture failure, edema, prolonged postoperative pain, mild inflammation, and necrosis. The certainty of evidence was very low on all outcomes. CONCLUSIONS:Although clitoral reconstructive surgery for FGM seems safe and effective, preoperative sexual health counseling should be offered. Women should be clearly informed about the risks and the limited evidence of possible benefits of clitoral reconstructive surgery, and their assessment and treatment should follow current scientific evidence and best clinical practice.

Background: The burden of sickle cell anaemia (SCA) is worsening globally. Recognition of paediatric SCA burden is vital to comprehending the overall SCA burden. Aim was to determine the prevalence, disease manifestations and outcomes of paediatric SCA. Materials and Methods: It was a retrospective study of all children with SCA, 0.5 year (6months) - 17 years old, managed from 2018 through 2023. Data obtained were sex, age at first visit per year, diagnoses and date per visit, location (clinics or emergency-room) of visit, intervals between visits, and death. Disease manifestations per subject were summarized into diagnosis while default was defined as >3 months visit interval. Results: Of the 532 subjects, 55.6% were males with overall median (interquartile [IQR]) age on first visit of 9 (5 - 13) years. On average, paediatric SCA constituted 4% of first visits per year. There were 252 sick visits per year, 544 diagnoses per year and 146 hospitalisations per year. Commonest diagnosis in emergency-room and clinics were bone pain crises (46.2%) and steady-state (48.5%), respectively. The 11 - 17-year-olds were more likely to have bone pain crises than 0.5 - 4-year-olds (Odds Ratio [OR] 0.381; 95%CI: 0.487-0.787) and 5 - 9-year-olds (OR 0.298; 95%CI: 0.573-0.861). They were also more likely to have avascular necrosis than the 0.5 - 4-year-olds (OR 0.789; 95%CI: 0.047-0.938) and 5 - 9-year-olds (OR 0.777; 95%CI: 0.064-0.781). Overall median (IQR) default time was 6 (5 - 7) months with more defaults (85.1%) than compliants (14.9%) (p<0.001) while 0.56% died. Conclusion: The overall prevalence of Paediatric SCA in the region is 4% with approximately one hospitalisation per sick visit and more than one diagnoses per visit. There is a high default rate but a low mortality rate (0.56%). Sustained improvement in the management of SCA, from childhood through adulthood, may help alleviate the increasing burden of the condition.

BackgroundRetinoblastoma is curable in industrialized countries. However, it is associated with mortality in resource-poor nations due to disparities and poor access to eyecare. The aim was to determine the relationships between patient-related factors and clinical outcomes of retinoblastoma in a tertiary hospital in Nigeria.Material and methodsThis was a retrospective study of all children diagnosed and treated for retinoblastoma from January 2017 through December 2022. Information obtained from their records included bio-socioeconomic data, symptoms, lag time from initial symptoms, staging, treatment, and survival outcome.ResultsFifty-three patients, aged 6–88 months on first hospital presentation were recruited. There were 29 (54.7%) females. Twenty (37.7%) patients died. Majority were last child of their parents (62.3%) with parental low socioeconomic class (86.8%) and lived in rural areas (50.9%). The median (interquartile) age at diagnosis [24 (18–36) months, p = 0.005] and lag time [13 (6–20)months, p = 0.274] were lower in those who survived than in those who died. The prevalence of bilateral disease (20.8%, p = 0.002), brain metastasis (22.6%, p < 0.001), stage IV disease (18.9%, p = 0.01) and relapse (34%, p < 0.001) was higher among the patients who died. The median (interquartile) overall survival (OS) was 22 (11.77–32.23)months with a 1-year OS of 63%. Treatment with only chemotherapy [HR 4.76 (95%CI:1.726–13.128)], incomplete chemotherapy [HR 5.61 (95%CI:1.271–24.741)], relapse [HR 5.98 (95%CI:1.376–25.983)] and eye surgery delayed after 3 chemotherapy cycles [HR 8.22 (95%CI:1.087–62.239)] were predictors of mortality.ConclusionEarly presentation of retinoblastoma may lead to improved survival if chemotherapy and eye surgery are appropriately performed. Routine screening and immediate referral of retinoblastoma, particularly in rural areas, are recommended.

Introduction: Diarrhoea is the second leading cause of under-five mortality globally and ranks second among the top 10 priority child health problems in Nigeria. The World Health Organization (WHO) has recommended some cost-effective, evidence- based interventions for diarrhoea case management. It is needful to evaluate the current practice in the treatment of diarrhoea in under-fives in health facilities in the country.Objective: To determine the extent to which current treatment practice for diarrhoea in underfives conforms to the WHO recommendation.Method: A clinical audit was conducted between May and June 2013 in 32 health facilities in the Southern Senatorial district of Cross River State, Nigeria. Trained field workers extracted information from patients’ case records using a validated audit tool. Treatment was checked as appropriate, inappropriate, wrong or none, based on prescription on patients’ case records.Result: Of the 370 case records audited, prescription for diarrhoea was appropriate in 40 (10.8%), inappropriate in 231 (62.4%), wrong in 82 (22.2%) and no prescription was made in 17 (4.6%).Conclusion: Treatment of diarrhoea in under-fives in health facilities in the State is suboptimum. Retraining of health workers on the current WHO and UNICEF treatment guidelines is highly recommended.Keywords: Diarrhoea, Underfives, Health Facilities, Prescription, Clinical Audit

Introduction: Cancers invade and destroy various parts of the body leading to death, if untreated. The burden of pediatric cancer is rising, especially in resource-poor regions. The aim of the study was to determine the incidence of childhood cancer types, basis of diagnosis, therapy received, and outcomes. Materials and Methods: This was a retrospective study of children aged 0-17 who were diagnosed and treated for cancer from January 2013 to December 2022. Data obtained included biodata, diagnoses, initial disease stage, diagnostic investigation results and treatments from medical records. Other outcomes assessed were relapse, abandonment of therapy, and death. Results: Of the 229 patients, males were 57.6%, 51.5% were in age-group 0-4 years and mean(SD) annual cancer crude incidence rate (CIR) was 0.29(0.09)/100,000 children. Retinoblastoma increased from 0.16/100,000 children in 2013 to 0.27/100,000 children in 2022 and had the highest average age-standardized incidence rate (0.11/100,000 children). Other malignancies had annual CIR between 0.01 and 0.08/100,000 children. The most common method of diagnosis was primary site histology (39.7%). Majority had late-stage disease (66.4%), incomplete chemotherapy (62.5%), no surgery (54.5%), and no radiotherapy (99.1%). There was disease relapse (20.5%), treatment abandonment (42.8%), discharged against medical advice (23.6%) and death (29.7%). More males than females died (1.5:1). The crude mortality rate of retinoblastoma increased from 0.01 to 0.12/100,000 children, while others fluctuated between 0.01 and 0.04/100,000 children. The average age-standardized mortality rate was highest in 0–4 years’ age group (48.5%). Conclusion: The rate of new cancers, particularly retinoblastoma, is rising in our locality. Majority present in advanced disease and are not effectively treated, resulting in increasing mortality rates. Periodic audit of childhood cancer burden may help relevant stakeholders in determining ways of curbing these worsening pediatric cancer trends.

Introduction: Artemether- lumefantrine (AL), the most frequently prescribed ACTs for uncomplicated P. falciparum malaria, requires multiple doses which may militate against adherence. It is necessary to evaluate the efficacy and safety of single dose ACT like Artemisininnaphthoquine (ANQ) to enhance adherence. Methods: This was an open label randomized controlled clinical trial. Eligible children were assigned to receive either a single dose of ANQ or six doses of AL following parental consent. A total of 108 children aged 5 – 14 years with uncomplicated falciparum malaria were enrolled and assigned as follows: 58 (ANQ) and 50 (AL). Participants were observed for 28 days and clinical and parasitological assessments carried out. Outcomes were assessed based on World Health Organization protocol. Results: A total of 97 patients completed the study. Overall 28- day cure rate was 87.0% (47/54) and 81.4% (35/43) for ANQ and AL respectively. One patient (2.2%) in the AL group had Early Treatment Failure while seven (16.3%) had Late Parasitological Failure (LPF). LPF was also reported in seven (13.0%) patients in the ANQ group. There was no Late Clinical Failure. A mild selflimiting papular rash was noted in one child in ANQ group. There was no serious adverse event. Conclusions: The therapeutic efficacies of ANQ and AL were comparable. A more robust, adequately powered, dose optimization study with PCR-confirmed parasitological outcome measures is needed.

Background: The six dose regimen of Artemether- Lumefantrine (AL), has high efficacy in clinical trials and is the first -line drug for treating uncomplicated malaria in Nigeria. The complex dosage schedule could militate against its effectiveness.Objective: To assess the effectiveness of AL prescribed under routineoutpatient conditions in the treatment of uncomplicated malaria.Methods: An open label, noncomparative trial to assess the effectivenessof AL in children 6 to 59 months with uncomplicated P. falciparum and parasite density between 1,000 and 250,000/ìL. Enrolled children received 6-dose course of AL (20/120mg tablets). The first dose was administered in the health facility and caregivers were instructed on how to administerthe remaining five doses at home.Results: Of the 1035 screened, 215 eligible children were enrolled and193 completed the study. Twenty two (22) patients withdrew from thestudy (18 were lost to follow-up, 3 violated protocol and 1 withdrewconsent). Adequate clinical and parasitological response (ACPR) was observed in 90.7%; late clinical failure in 7 (3.6%) and late parasitologicalfailure in 11 (5.7%).Conclusion: This study showed high efficacy of AL in treating uncomplicatedP. falciparum malaria in under-fives in Nigeria. Adherence by caregivers to the treatment regimen was quite good and so, should continue to be used in the home setting.Key words: Artemetherlumefantrine, effectiveness, adherence, uncomplicated malaria.

Pediatric-type follicular lymphoma (PFL) is a rare, nonaggressive, slow-growing (indolent), non-Hodgkin lymphoma that is typically seen in males as a localized disease with excellent outcomes. It is largely different from follicular lymphoma (FL). Few published studies on PFL are case series in developed nations. We report on a patient with advanced PFL, a 14-year-old female with 5-year history of neck swellings, abdominal distension for a month, and pericardial effusion, among others. The swellings waxed and waned; and involved all the peripheral lymph nodes. Tuberculosis (TB) GeneXpert and human immunodeficiency virus (HIV) screening were negative. She received anti-TB drugs prior to presentation in our hospital where nodal histopathology showed effaced architecture with diffuse follicles and abundant blastoid cells as well as negative CD5 and BCL2, and positive CD10 and CD20. Diagnosis of PFL (stage 3) was made. She completed six courses of cyclophosphamide, doxorubicin, vincristine, and prednisolone and is well 9 months after therapy. The PFL usually presents with stage 1 or 2 disease unlike in the index female case that was also complicated by effusion and ascites due to late presentation. It responded to chemotherapy and has not reoccurred; in contrast to classic FL and reactive follicular hyperplasia (RFH) which should be differentiated from PFL. Although RFH can be caused by TB or HIV, they are not causes of malignant lymphadenopathy. Physicians should be aware of PFL which may present in high clinical stages, but still retain its good prognosis, for the purposes of counseling.

Background: Retinoblastoma, although rare, is the most frequently occurring primary intraocular tumor of childhood. While a cure is often achieved where appropriate treatment is instituted early in the disease, late presentation often leads to unsuccessful treatment interventions. Aim: The aim of this study is to provide baseline information on the clinical presentation of retinoblastoma as seen in a tertiary pediatric eye care facility in Calabar, Nigeria. Materials and Methods: A retrospective review of case files of children presenting to the Calabar Children's Eye Center (CCEC) with retinoblastoma over 18 months from January 1, 2018 to June 30, 2019 was done. Results: Data were collected from 39 children with retinoblastoma who met the inclusion criteria. There were 22 (56.4%) males and 17 (43.6%) females, and the age range was 7–41 months, with a mean age of 25.6 (±9.0) months. Unilateral disease was seen in 27 (69.2%) participants, whereas 12 (30.8%) had bilateral disease. Although multiple symptoms were seen in many participants protrusion of eye was the most frequently occurring first symptom, (17, 44.0%) followed by red eye (13, 33.0%), whitespot in eye (5, 13.0%), and abnormal alignment (4, 10.0%) among study participants. The lag time from recognition of symptoms to initial consultation ranged from 1 to 25 months, with a mean lag time of 9.13 ± 5.68 months. The ICRB classification system was most frequently used, 27 (69.2%), followed by cTNMH 11 (28.2%), and International Intraocular Retinoblastoma Classification 1 (2.6%). The International Retinoblastoma Staging System was representative. Of the 78 eyes studied, (51, 65.3%) had different stages of retinoblastoma with the majority presenting as advanced retinoblastoma (46, 90.2%). Conclusions: Retinoblastoma is seen at the CCEC. Although the most frequent symptom was protrusion of eye, the lag time was often several months long. Most patients presented late with advanced ocular retinoblastoma and or extraocular disease.

Prolonged QTc interval, a risk factor for ventricular arrhythmia, occurs in sickle cell anemia. The aim of this study was to determine the risk of prolonged QTc interval and its relationship with vaso-occlusive painful crises (VOCs) and follow-up steady-state in the same children with sickle cell anemia. This prospective cohort study enrolled 38 subjects, aged 5-17 years. History of bone pain and examination were obtained during VOC and steady-state. Assessment of QTc interval was with 12-lead electrocardiography. The QTc interval value >0.440 seconds was taken as prolonged. Median (interquartile range) of QTc interval was higher during VOC [0.447 (0.438-0.459) seconds] than during steady-state [0.435 (0.417-0.440) seconds]. Risk of prolonged QTc interval was higher during VOC (68.4%) than in steady-state (21.1%) with relative risk of 3.250 [95% confidence interval (CI) = 1.692-6.241]. Prolonged QTc interval was likely to occur [area under curve (AUC) = 0.759, p<0.001] during VOC with 68.4% sensitivity, 78.9% specificity and at cutoff point of 0.441 seconds. Prolonged QTc interval negatively correlated with packed cell volume (PCV) during VOC [rs (36) = -0.14, p = 0.387]. Binary logistics of the combined effect of PCV and gender on QTc interval showed that during VOC, males were more likely to have prolonged QTc [odds ratio (OR): 1.337 (95% CI: 0.327-5.464; p = 0.686]. Children with sickle cell anemia, particularly males, were three-times more likely to have prolonged QTc interval during VOC when QTc interval was >0.441 seconds. Routine electrocardiography may help to identify those with QTc intervals above this threshold for prompt cardiac-oriented management.

Background: The severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic has continued to disrupt medical care among patients with sickle cell anemia (SCA). The city lockdowns and restrictions to minimize virus transmission in countries have created gaps in the optimal management of children with SCA. Aim: The aim of this study was to access the clinical experience in the use of mobile health telemedicine for the care of children with SCA. Methods: At the start of national lockdown, text messages were sent to parents of children with SCA who are attending a tertiary hospital in Nigeria. The message included advice to call consultants in the pediatric hemato-oncology unit whenever their wards were sick or due for a routine clinic visit. Information obtained include date of call or text message, complaints, intervention prescribed, and feedback from the parents. Results: There were 115 calls and 43 texts from the parents from April through July 2020. The proportion of calls increased from 16.5% to 33.9%, while texts increased from 23.3% to 30.2% over the months. Responses were significant ( P = 0.047). Respiratory symptoms (40%) were the most common complaints. The most frequent interventions were counseling (59%) and drug prescriptions (31%) with the resolution of most symptoms by day 7 ( P < 0.001). Parents (60.8%) preferred phone interactions across the months ( P < 0.05). No confirmed case of SARS-CoV-2 was recorded. Conclusion: Mobile health telemedicine is a beneficial tool in the maintenance of care and possibly prevention of SARS-CoV-2 infection among children with SCA in a resource-limited region. Efforts should be made by stakeholders to institute and promulgate telemedicine during this pandemic.

Introduction fever is the primary symptom of most childhood illnesses and a cause of concern to their caregivers. The antipyretics commonly used to treat fever are ibuprofen and paracetamol. Most studies on the effectiveness of ibuprofen and paracetamol in treating fever in under-fives were conducted in Europe and North America with very few in African children. This study was aimed at assessing the effectiveness and safety of a single dose therapy of ibuprofen versus paracetamol for treating childhood fever in Nigeria. Methods a randomized, controlled clinical trial was conducted in the University of Calabar Teaching Hospital, in Nigeria. A total of 140 eligible children aged 6-59 months with tympanic temperature of 38°C-40°C were enrolled, and 70 of them were assigned to one arm that received a single dose of ibuprofen (10mg/kg) and 70 had paracetamol (15mg/kg). After drug administration, the children were admitted and observed in the hospital for six hours during which period a half-hourly temperature measurement and monitoring for adverse events were done. Results the overall result showed that ibuprofen had a better fever reducing effect compared to paracetamol. The proportion of afebrile children in the ibuprofen versus paracetamol group at 1.5-2.5 hours of administration of the drugs was statistically significant (p = 0.04). The adverse events of both drugs were mild and quite comparable with vomiting being the commonest. Conclusion ibuprofen is more effective in the treating fever in under-fives compared to paracetamol. The adverse events of both drugs were mild and comparable.

Background In children with sickle cell anaemia (SCA), ischaemic electrocardiogram (ECG) changes occur during both vaso-occlusive crises (VOC) and the steady state. Myocardial ischaemia evidenced by an ischaemic pattern on ECG may lead to myocardial injury which is evidenced by elevated serum cardiac troponin T (cTnT). Occasionally, the myocardial injury is fatal. Aim To determine the relationship between raised serum cTnT levels and an ischaemic ECG pattern in children with SCA. Methods This was a dual study design comprising a prospective cohort study of a group of children with SCA observed during VOC and 6 weeks later during follow-up steady state, and a case-control study of SCA children and apparently healthy children. The subjects were 34 SCA children aged 5-17 years and 34 age- and sex-matched apparently healthy controls with haemoglobin genotype AA attending University of Calabar Teaching Hospital. VOC was diagnosed by clinical examination and a history of bone pain. During VOC and follow-up steady state, an ECG was performed and blood taken for serum cTnT estimation. In the apparently healthy children, only serum cTnT was estimated. Serum cTnT was analysed by electrochemiluminescence immune-assay. Ischaemic ECG was assessed using the World Heart Federation criteria. Results Twenty-eight (82.4%) SCA children had elevated serum cTnT during VOC and it was elevated in only six (17.6%) of them during the steady state. An ischaemic ECG was observed in 25 (73.5%) and 20 (58.8%) of them during VOC and the steady state, respectively. Ischaemic ECG identified SCA children with elevated cTnT during VOC (sensitivity 75%, specificity 33.3%) and the follow-up steady state (sensitivity 50%, specificity 39.3%). Measures of agreement between ECG and cTnT in detecting myocardial injury were poor during VOC (kappa 0.07,p= 0.68) and the follow-up steady state (kappa - 0.06,p= 0.63). Conclusions Most SCA children have an ischaemic ECG with elevated serum cTnT, especially during VOC, which suggests ischaemic-induced cardiac injury. However, elevated serum cTnT can occur without an ischaemic ECG andvice versa. Performing only electrocardiography or cTnT to detect ischaemia-induced cardiac injury may be misleading. Therefore, when there is a high index of suspicion, both tests should be undertaken, especially during VOC, to ensure prompt, effective treatment.

To ascertain the impact or otherwise of the HIV/AIDS pandemic on the pattern of cancers in children and adolescents in Calabar, Nigeria, during the post-antiretroviral period, 2009 to 2013. Data from the Calabar Cancer Registry for the period, 2009 to 2013, will be reviewed and only cancers in cases aged 0 to 19 years will be analyzed, the focus being mainly on the basis of diagnosis, age, sex, tumor morphology, and topography. Of the 719 new cancer cases reported over the 5-year period in Calabar, Nigeria, 7.8% were aged 0 to 19 years. Majority (61%) occurred in children aged below 10 years, while the remaining affected those aged 10 to 19 years. Slightly more males (55.4%) than females (44.5%) were affected. Lymphohematological cancers were commonest (41%), with Burkitt and Hodgkin lymphoma being the majority, affecting predominantly those aged 5 years and above. The eye was the second commonest site of malignancies in children and adolescents, with more females being affected, whereas more males had renal cancers. The HIV status of these patients was not known at the time of diagnosis. There is a striking predominance of HIV/AIDS-defining cancers of the lymphohemopoeitic system in the young children and adolescents in Calabar. Follow-up and monitoring of those receiving treatment and screening of all new cases for HIV infection will be required to determine their survival rates and compliance to the chemotherapeutic and antiretroviral drugs if HIV seropositive.

Background: Nigeria commenced a phased programmatic deployment of rapid diagnostic tests (RDT) at the primary health care (PHC) facility levels since 2011. Despite various efforts, the national testing rate for malaria is still very low. The uptake of RDT has been variable. This study was undertaken to determine the provider and patient perceptions to RDT use at the PHC level in Nigeria with their implications for improving uptake and compliance. Methods: A cross-sectional survey was conducted in 120 randomly selected PHCs across six states, across the sixgeopolitical zones of Nigeria in January 2013. Health facility staff interviews were conducted to assess health workers (HW) perception, prescription practices and determinants of RDT use. Patient exit interviews were conducted to assess patient perception of RDT from ten patients/caregivers who met the eligibility criterion and were consecutively selected in each PHC, and to determine HW's compliance with RDT test results indirectly. Community members, each selected by their ward development committees in each Local Government Area were recruited for focus group discussion on their perceptions to RDT use. Results: Health workers would use RDT results because of confidence in RDT results (95.4%) and its reduction in irrational use of artemisinin-based combination therapy (ACT) (87.2%). However, in Enugu state, RDT was not used by health workers because of the pervasive notion RDT that results were inaccurate. Among the 1207 exit interviews conducted, 549 (45.5%) had received RDT test. Compliance rate (administering ACT to positive patients and withholding ACT from negative patients) from patient exit interviews was 90.2%. Among caregivers/patients who had RDT done, over 95% knew that RDT tested for malaria, felt it was necessary and liked the test. Age of patients less than 5 years (p= 0.04) and "high" educational status (p = 0.0006) were factors influencing HW's prescription of ACT to RDT negative patients. Conclusion: The study demonstrated positive perception to RDT use by HW and among community members with good compliance rate among health workers at the PHC level. This positive perception should be explored in improving the current low level of malaria testing in Nigeria while addressing the influence of age on HW administration of ACT to RDT negative cases.

BACKGROUND:Although complementary feeding is a universal practice, the methods and manner in which it is practiced vary between cultures, individuals and socioeconomic classes. The period of complementary feeding is a critical time of transition in the life of an infant, and inappropriate complementary feeding practices, with their associated adverse health consequences, remain a significant global public health problem. Educational interventions are widely acknowledged as effective in promoting public health strategy, and those aimed at improving complementary feeding practices provide information about proper complementary feeding practices to caregivers of infants/children. It is therefore important to summarise evidence on the effectiveness of educational interventions to improve the complementary feeding practices of caregivers of infants. OBJECTIVES:To assess the effectiveness of educational interventions for improving the complementary feeding (weaning) practices of primary caregivers of children of complementary feeding age, and related health and growth outcomes in infants. SEARCH METHODS:In November 2017, we searched CENTRAL, MEDLINE, Embase, 10 other databases and two trials registers. We also searched the reference lists of relevant studies and reviews to identify any additional studies. We did not limit the searches by date, language or publication status. SELECTION CRITERIA:Randomised controlled trials (RCTs), comparing educational interventions to no intervention, usual practice, or educational interventions provided in conjunction with another intervention, so long as the educational intervention was only available in the experimental group and the adjunctive intervention was available to the control group. Study participants included caregivers of infants aged 4 to 24 months undergoing complementary feeding. Pregnant women who were expected to give birth and commence complementary feeding during the period of the study were also included. DATA COLLECTION AND ANALYSIS:Two review authors independently extracted data on participants, settings, interventions, methodology and outcomes using a specifically-developed and piloted data extraction form. We calculated risk ratios (RR) and 95% confidence intervals (CIs) for dichotomous data, and mean differences (MD) and 95% CIs for continuous data. Where data permitted, we conducted a meta-analysis using a random-effects model. We assessed the included studies for risk of bias and also assessed the quality of evidence using the GRADE approach. MAIN RESULTS:We included 23 studies (from 35 reports) with a total of 11,170 caregiver-infant pairs who were randomly assigned to receive an educational intervention delivered to the caregiver or usual care. Nineteen of the included studies were community-based studies while four were facility-based studies. In addition, 13 of the included studies were cluster-randomised while the others were individually randomised. Generally, the interventions were focused on the introduction of complementary feeding at the appropriate time, the types and amount of complementary foods to be fed to infants, and hygiene. Using the GRADE criteria, we assessed the quality of the evidence as moderate, mostly due to inadequate allocation concealment and insufficient blinding.Educational interventions led to improvements in complementary feeding practices for age at introduction of complementary foods (average RR 0.88, 95% CI 0.83 to 0.94; 4 studies, 1738 children; moderate-quality evidence) and hygiene practices (average RR 1.38, 95% CI 1.23 to 1.55; 4 studies, 2029 participants; moderate-quality evidence). For duration of exclusive breastfeeding, pooled results were compatible with both a reduction and an increase in the outcome (average RR 1.58, 95% CI 0.77 to 3.22; 3 studies, 1544 children; very low-quality evidence). There was limited (low to very low-quality) evidence of an effect for all growth outcomes.Quality of evidenceThere is moderate to very low-quality evidence that educational interventions can improve complementary feeding practices but insufficient evidence to conclude that it impacts growth outcomes. AUTHORS' CONCLUSIONS:Overall, we found evidence that education improves complementary feeding practices.

BACKGROUND:Vulvar and clitoral pain are known complications of female genital mutilation (FGM). Several interventions have been used to treat these conditions. This review focuses on surgical and nonsurgical interventions to improve vulvar and clitoral pain in women living with FGM. OBJECTIVE:To evaluate the impact of nonsurgical and surgical interventions for alleviating vulvar and clitoral pain in women living with any type of FGM and to assess the associated adverse events. SEARCH STRATEGY:The search included the following major databases: Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov. These were searched from inception until August 10, 2015 without any language restrictions. SELECTION CRITERIA:Study designs included randomized controlled trials, cluster randomized trials, nonrandomized trials, cohort studies, case-control studies, controlled before-and-after studies, historical control studies, and interrupted time series with reported data comparing outcomes among women with FGM who were treated for clitoral or vulvar pain with either surgical or nonsurgical interventions. DATA COLLECTION AND ANALYSIS:Two team members independently screened studies for eligibility. RESULTS:No studies were included. CONCLUSION:Limited information exists on management of vulvar and clitoral pain in women living with FGM. This constitutes an important area for further research. PROSPERO REGISTRATION:CRD42015024521.