Prevalence of acute kidney injury and its characteristics among neonates with suspected sepsis in a tertiary hospital in Kenya.

Introduction: Unique aspects of neonatal renal physiology enhance the occurrence of Acute Kidney Injury (AKI) as a complication of neonatal sepsis. The study sought to determine prevalence of AKI and its characteristics in neonates with suspected sepsis. Methods: A cross-sectional study was conducted at Kenyatta National Hospital among neonates aged 0-28 days. AKI was defined as serum creatinine of more than 100µmmol/l. Results: Among 332 neonates included 120 had AKI giving a prevalence of 36.1% (95% CI 31 to 41.6). Based on RIFLE criteria the commonest AKI presentation was Failure 72 (62.6%, 95% CI 53.6 to 71.6), followed by Injury 26 (22.6%, 95% CI 14.8 to 30.4) and then Risk 17 (14.8%, 95% CI 8.2 to 21.3). AKI was more common in neonates with suspected late onset sepsis (p=0.004). Maternal fever in the preceding week to delivery and presence of either puerperal sepsis or post-partum hemorrhage were significantly associated with severe AKI (p=0.004 and p=0.038). Conclusion: Prevalence of AKI was high; those with suspected late onset sepsis were more likely to develop AKI compared to early onset sepsis. Presence of maternal fever preceding delivery and presence of either puerperal sepsis or postpartum hemorrhage were associated with severe forms of AKI.

Prevalence of non-alcoholic fatty liver disease in overweight and obese children seeking ambulatory healthcare in Nairobi, Kenya.

BACKGROUND: While linked to obesity and associated with an increased cardiovascular morbidity, non-alcoholic fatty liver disease (NAFLD) is an often-asymptomatic cause of chronic liver disease in children. Early detection provides opportunity for interventions to curb progression. Childhood obesity is on the rise in low/middle-income countries, but cause-specific mortality data associated with liver disease are scanty. Establishing the prevalence of NAFLD in overweight and obese Kenyan children would guide in public health policies aimed at early screening and intervention. OBJECTIVES: To investigate prevalence of NAFLD in overweight and obese children aged 6-18 years using liver ultrasonography. METHODOLOGY: This was a cross-sectional survey. After obtaining informed consent, a questionnaire was administered, and blood pressure (BP) measured. Liver ultrasonography was performed to assess fatty changes. Categorical variables were analysed using frequency and percentages. χ2 test and multiple logistic regression model were used to determine relationship between exposure and outcome variables. RESULTS: Prevalence of NAFLD was 26.2% (27/103, 95% CI=18.0% to 35.8%). There was no association between sex and NAFLD (OR1.13, p=0.82; 95% CI=0.4 to 3.2). Obese children were four times more likely to have NAFLD compared with overweight children (OR=4.52, p=0.02; 95% CI=1.4 to 19.0). About 40.8% (n=41) had elevated BP, but there was no association with NAFLD (OR=2.06; p=0.27; 95% CI=0.6 to 7.6). Older children (13-18 years) were more likely to have NAFLD (OR 4.42; p=0.03; 95% CI=1.2 to 17.9). CONCLUSION: Prevalence of NAFLD was high in overweight and obese school children in Nairobi. Further studies are needed to identify modifiable risk factors to arrest progression and prevent sequelae.

Depression and its associated factors: perceived stress, social support, substance use and related sociodemographic risk factors in medical school residents in Nairobi, Kenya.

BACKGROUND: Little data exists regarding depression and its associated factors in medical residents and doctors in Sub-Saharan Africa. Residents are at high risk of developing depression owing to the stressful nature of their medical practice and academic training. Depression in medical residents leads to decreased clinical efficiency, and poor academic performance; it can also lead to substance abuse and suicide. Our primary aim was to measure depression prevalence among medical residents in Kenya's largest national teaching and referral hospital. Secondary aims were to describe how depression was associated with perceived stress, perceived social support, substance use, and educational environment. METHODS: We sampled 338 residents belonging to 8 different specialties using self administered questionnaires in this cross-sectional survey between October 2019 and February 2020. Questionnaires included: sociodemographics, the Centres for Epidemiology Depression Scale - Revised, Perceived Stress Scale, Multidimensional Scale of Perceived Social Support, Alcohol, Smoking and Substance Involvement Screening Test, and Postgraduate Hospital Educational Environment Measure. Bivariate and multivariate linear regression were used to assess for risk factors for depression. RESULTS: Mean participant age was 31.8 years and 53.4% were males. Most residents (70.4%) reported no to mild depressive symptoms, 12.7% had moderate, and 16.9% had severe depressive symptoms. Most residents had high social support (71.8%) and moderate stress (61.6%). The educational environment was rated as more positive than negative by 46.3% of residents. Bivariate analyses revealed significant correlations between depressive symptoms, perceived stress, substance use, perceived social support, and educational environment. Multivariate analysis showed that depression was strongly associated with: fewer hours of sleep (ß = - 0.683, p = 0.002), high perceived stress (ß = 0.709, p < 0.001) and low perceived social support (ß = - 2.19, p < 0.001). CONCLUSIONS: Only 30% of medical residents in our study had moderate and severe depressive symptoms. Most residents in our study reported high levels of social support, and moderate levels of stress. Though their overall appraisal of medical residency experience was positive, mental health support and self-care skills in the training of medical professionals needs prioritization.

Prevalence of rotavirus infection among children with acute diarrhoea after rotavirus vaccine introduction in Kenya, a hospital cross-sectional study.

BACKGROUND: Rotavirus infection is the most common cause of acute gastroenteritis globally in children under 5 years of age and is responsible for approximately 5% of all child deaths yearly. Rotavirus vaccination is considered an effective public health strategy to prevent infection and reduce the severity of disease. Multi-centre country trials on rotavirus vaccines demonstrated efficacy rates of more than 85% in developed countries but only about 65% in developing nations. Rotavirus vaccination was introduced into the Kenya Expanded Programme on Immunization (KEPI) in 2014. The objective of our study was to determine the prevalence of rotavirus infection, severity of acute diarrhoea and to determine the rotavirus vaccination status among children aged 3-24 months presenting with acute diarrhoea at Kenyatta National Hospital after introduction of rotavirus vaccine in Kenya. METHODS: A total of 365 children aged 3-24 months presenting with acute diarrhoea at KNH were recruited from August 2016 to April 2017. Data on rotavirus vaccination status, nutritional status, feeding practices and sociodemographic characteristics were obtained and a full clinical evaluation of the patients was done. Severity of the gastroenteritis was assessed using the 20 point Vesikari Clinical Severity Scoring System. The children who were admitted were followed up for 7 days using hospital ward registers. Comorbid conditions were established from patient's clinical records and physical examination. Stool specimens from study participants were tested for rotavirus using a commercially available enzyme linked immunosorbent immunoassay kit- ProSpecT Rotavirus Microplate Assay. RESULTS: Majority of the children (96.7%) had received rotavirus vaccinations. The overall rotavirus prevalence was 14.5% and was higher among 17-24 months at 19.5%. The prevalence somewhat differed by gender, nutritional status, exclusive breastfeeding status, age and education level of mother/caregiver. Overall, a half of the children had severe acute diarrhoea and there were some differences in severity by child/mother characteristics. CONCLUSION: There is still burden of rotavirus diarrhoea after introduction of rotavirus vaccine and the prevalence varies by child characteristics.

Overnutrition: Does Complementary Feeding Play a Role?

Globally, obesity is considered an epidemic due to an increase in its prevalence and severity especially among young children and adolescents. This nutritional disorder is not limited to affluent countries as it is becoming increasingly prevalent in developing countries. Obesity is associated not only with cardiovascular, endocrine, gastrointestinal, orthopedic, and respiratory diseases, but also with psychological complications, implying a problem of far-reaching consequences for health and health services. Recently, evidence-based studies have shown that the duration of exclusive breastfeeding and the type of complementary feeds during the weaning period of an infant may have an effect on overnutrition later on in life. Thus, stemming the tide of obesity early on in life would potentially decrease the prevalence and complications of adult obesity, which could have significant implications for health care and the economy at large. This review explores the role of complementary feeding in obesity and approaches to prevention and treatment of childhood obesity by summarizing key systematic reviews. In conclusion, we found that although the relationship between complementary feeding and childhood obesity has been suspected for a long time, specific risk parameters are not as firmly established. Early introduction of complementary feeds (before the 4th month of life), high protein and energy content of feeds, and nonadherence to feeding guidelines may be associated with overweight and obesity later in life.

Caregiver oral rehydration solution fluid monitoring charts versus standard care for the management of some dehydration among Kenyan children: a randomized controlled trial.

Background: Diarrhoea is a major cause of child mortality. Although oral rehydration solution (ORS) is an efficacious intervention for correcting dehydration, inadequate monitoring may limit its effectiveness in routine settings. We evaluated the effect of using a caregiver-administered chart to monitor oral fluid therapy on hydration status among children with some dehydration. Methods: An open-label randomized controlled trial was conducted among children 2-59 months of age. ORS fluid monitoring charts were given to caregivers in the intervention arm to record the hourly intake of ORS. ORS was administered without charting in the control arm. The primary outcome was dehydration defined by the presence of clinical signs of some dehydration, severe dehydration or shock assessed 4 h after initiation of treatment. We also assessed the acceptability of the charts among caregivers. Results: We evaluated 252 patients for the primary endpoint. Among those who received the intervention, 7/122 (5.7%) were still dehydrated following 4 h of ORS administration vs 20/130 (15.4%) in the control group (risk ratio 0.37 [95% confidence interval 0.16-0.85]). Caregivers in the intervention arm reported positive experiences using the fluid charts. Conclusions: The use of fluid monitoring charts reduced the frequency of dehydration and was well accepted by caregivers, representing a promising innovation for the management of diarrhoea and dehydration in resource-limited settings.

Prevalence and factors associated with preterm birth at kenyatta national hospital.

BACKGROUND: The World Health Organization estimates the prevalence of preterm birth to be 5-18% across 184 countries of the world. Statistics from countries with reliable data show that preterm birth is on the rise. About a third of neonatal deaths are directly attributed to prematurity and this has hindered the achievement of Millennium Development Goal-4 target. Locally, few studies have looked at the prevalence of preterm delivery and factors associated with it. This study determined the prevalence of preterm birth and the factors associated with preterm delivery at Kenyatta National Hospital in Nairobi, Kenya. METHODS: A cross-sectional descriptive study was conducted at the maternity unit of Kenyatta National Hospital in Nairobi, Kenya in December 2013. A total of 322 mothers who met the eligibility criteria and their babies were enrolled into the study. Mothers were interviewed using a standard pretested questionnaire and additional data extracted from medical records. The mothers' nutritional status was assessed using mid-upper arm circumference measured on the left. Gestational age was assessed clinically using the Finnstrom Score. RESULTS: The prevalence of preterm birth was found to be 18.3%. Maternal age, parity, previous preterm birth, multiple gestation, pregnancy induced hypertension, antepartum hemorrhage, prolonged prelabor rupture of membranes and urinary tract infections were significantly associated with preterm birth (p = < 0.05) although maternal age less < 20 years appeared to be protective. Only pregnancy induced hypertension, antepartum hemorrhage and prolonged prelabor rupture of membranes remained significant after controlling for confounders. Marital status, level of education, smoking, alcohol use, antenatal clinic attendance, Human Immunodeficiency Virus status, anemia, maternal middle upper arm circumference and interpregnancy interval were not associated with preterm birth. CONCLUSIONS: The prevalence of preterm birth in Kenyatta National Hospital was 18.3%. Maternal age ≤ 20 years, parity > 4, twin gestation, maternal urinary tract infections, pregnancy induced hypertension, antepartum hemorrhage and prolonged prelabor rupture of membranes were significantly associated with preterm birth. The latter 3 were independent determinants of preterm birth. At-risk mothers should receive intensified antenatal care to mitigate preterm birth.

Racecadotril for the treatment of severe acute watery diarrhoea in children admitted to a tertiary hospital in Kenya.

BACKGROUND: Diarrhoea is the second most common cause of death in children under 5 years of age in Kenya. It is usually treated with oral rehydration, zinc and continued feeding. Racecadotril has been in use for over 2 decades; however, there is a paucity of data regarding its efficacy from Africa. OBJECTIVES: The objectives of this study were: to compare the number of stools in the first 48 hours in children with severe gastroenteritis requiring admission and treated with either racecadotril or placebo, to study the impact of racecadotril on duration of inpatient stay as well as duration of diarrhoea and to describe the side effect profile of racecadotril. METHODS: This was a randomised, double-blinded, placebo-controlled trial. It enrolled children between the age of 3 and 60 months who were admitted with severe acute gastroenteritis. They received either racecadotril or placebo in addition to oral rehydration solution (ORS) and zinc and were followed up daily. RESULTS: 120 children were enrolled into the study. There were no differences in the demographics or outcomes between the 2 groups. Stools at 48 hours: median (IQR) of 5 (3-7) and 5 (2.5-7.5), respectively; p=0.63. The duration of inpatient stay: median (IQR): 4 days (1.5-6.5) and 4.5 (1.8-6.3); p=0.71. The duration of illness: 3 days (2-4) and 2 days (1-3); p=0.77. The relative risk of a severe adverse event was 3-fold higher in the drug group but was not statistically significant (95% CI 0.63 to 14.7); p=0.16. CONCLUSIONS: Racecadotril has no impact on the number of stools at 48 hours, the duration of hospital stay or the duration of diarrhoea in children admitted with severe gastroenteritis and managed with ORS and zinc. TRIAL REGISTRATION NUMBER: PACTR201403000694398; Pre-results.

Perspectives of host faculty and trainees on international visiting faculty to paediatric academic departments in East Africa.

BACKGROUND: Investments in faculty exchanges to build physician workforce capacity are increasing. Little attention has been paid to the expectations of host institution faculty and trainees. This prospective qualitative research study explored faculty and resident perspectives about guest faculty in paediatric departments in East Africa, asking (1) What are the benefits and challenges of hosting guest faculty, (2) What factors influence the effectiveness of faculty visits and (3) How do host institutions prepare for faculty visits? METHODS: We recruited 36 faculty members and residents from among four paediatric departments in East Africa to participate in semistructured interviews which were audio recorded and transcribed. Data were qualitatively analysed using principles of open coding and thematic analysis. We achieved saturation of themes. RESULTS: Benefits of faculty visits varied based on the size and needs of host institutions. Emergent themes included the importance of guest faculty time commitment, and mutual preparation to ensure that visit goals and scheduling met host needs. We documented conflicts that developed around guest emotional responses and ethical approaches to clinical resource limitations, which some hosts tried to prepare for and mitigate. Imbalance in resources led to power differentials; some hosts sought partnerships to re-establish control over the process of having guests. CONCLUSIONS: We identified that guest faculty can assist paediatric institutions in building capacity; however, effective visits require: (1) mutually agreed on goals with appropriate scheduling, visit length and commitment to ensure that the visits meet the host's needs, (2) careful selection and preparation of guest faculty to meet the host's goals, (3) emotional preparation by prospective guests along with host orientation to clinical work in the host's setting and (4) attention to funding sources for the visit and mitigation of resulting power differentials.

Mesalazine in the initial management of severely acutely malnourished children with environmental enteric dysfunction: a pilot randomized controlled trial.

BACKGROUND: Environmental enteric dysfunction (EED) is an acquired syndrome of impaired gastrointestinal mucosal barrier function that is thought to play a key role in the pathogenesis of stunting in early life. It has been conceptualized as an adaptive response to excess environmental pathogen exposure. However, it is clinically similar to other inflammatory enteropathies, which result from both host and environmental triggers, and for which immunomodulation is a cornerstone of therapy. METHODS: In this pilot double-blind randomized placebo-controlled trial, 44 children with severe acute malnutrition and evidence of EED were assigned to treatment with mesalazine or placebo for 28 days during nutritional rehabilitation. Primary outcomes were safety and acceptability of the intervention. RESULTS: Treatment with mesalazine was safe: there was no excess of adverse events, evidence of deterioration in intestinal barrier integrity or impact on nutritional recovery. There were modest reductions in several inflammatory markers with mesalazine compared to placebo. Depression of the growth hormone--insulin-like growth factor-1 axis was evident at enrollment and associated with inflammatory activation. Increases in the former and decreases in the latter correlated with linear growth. CONCLUSIONS: Intestinal inflammation in EED is non-essential for mucosal homeostasis and is at least partly maladaptive. Further trials of gut-specific immunomodulatory therapies targeting host inflammatory activation in order to optimize the growth benefits of nutritional rehabilitation and to address stunting are warranted. Funded by The Wellcome Trust. TRIAL REGISTRATION: Registered at Clinicaltrials.gov NCT01841099.

Effectiveness of sequential v. standard triple therapy for treatment of Helicobacter pylori infection in children in Nairobi, Kenya.

BACKGROUND: Once the diagnosis of Helicobacter pylori is confirmed, treatment requires at least two antibiotics and an acid inhibitor for a minimum of seven days. Unfortunately, treatment failures are being frequently reported. Treatment regimens that include sequential administration of antibiotics with acid inhibitors have been developed to try and increase the rate of eradication. OBJECTIVE: To determine the effectiveness of a novel 10-day sequential therapy compared with the standard 10-day triple therapy for treatment of H. pylori infection in children. METHODS: A double-blinded, randomised, controlled trial was conducted. Children under the age of 16 years with recurrent abdominal pain associated with dyspepsia and diagnosed with H. pylori by histology were randomly allocated either to a 10-day sequential treatment regimen or to a 10-day conventional triple therapy. Analysis of the outcome of this study was based on clinical improvement and confirmed H. pylori eradication based on stool H. pylori antigen detection and/or repeat endoscopy. RESULTS: Of the 71 patients included in the analysis, 45 (63.4%) were given the 10-day conventional treatment while 26 (36.6%) received the 10-day sequential treatment. There was no difference in clinical improvement after treatment in the two therapies. However, there was a significant difference in the eradication of H. pylori between the conventional v. sequential regimens (48.8% v. 84.6%, respectively; p=0.02, odds ratio 0.19). CONCLUSION: The sequential treatment had a significantly higher H. pylori eradication rate than the conventional treatment.

Who is to blame? Perspectives of caregivers on barriers to accessing healthcare for the under-fives in Butere District, Western Kenya.

BACKGROUND: Kenya, like many developing nations, continues to experience high childhood mortality in spite of the many efforts put in place by governments and international bodies to curb it. This study sought to investigate the barriers to accessing healthcare services for children aged less than five years in Butere District, a rural district experiencing high rates of mortality and morbidity despite having relatively better conditions for child survival. METHODS: Exit interviews were conducted among caregivers seeking healthcare for their children in mid 2007 in all the 6 public health facilities. Additionally, views from caregivers in the community, health workers and district health managers were sought through focus group discussions (FGDs) and key informant interviews (KIs). RESULTS: Three hundred and ninety-seven respondents were surveyed in exit interviews while 45 respondents participated in FGDs and KIs. Some practices by caregivers including early onset of child bearing, early supplementation, and utilization of traditional healers were thought to increase the risk of mortality and morbidity, although reported rates of mosquito net utilization and immunization coverage were high. The healthcare system posed barriers to access of healthcare for the under fives, through long waiting time, lack of drugs and poor services, incompetence and perceived poor attitudes of the health workers. FGDs also revealed wide-spread concerns and misconceptions about health care among the caregivers. CONCLUSION: Caregivers' actions were thought to influence children's progression to illness or health while the healthcare delivery system posed recurrent barriers to the accessing of healthcare for the under-fives. Actions on both fronts are necessary to reduce childhood mortality.