ADHERENCE TO PNEUMONIA GUIDELINES FOR CHILDREN 2 - 59 MONTHS AT GARRISA PROVINCIAL GENERAL HOSPITAL.

BACKGROUND: Clinical Practice Guidelines for childhood illnesses including pneumonia in Kenya are contained in the Ministry of Health Basic Paediatric Protocols. In the presence of a cough and/ or difficulty in breathing and increased respiratory rate for age, pneumonia is diagnosed. In addition to these the presence of lower chest wall indrawing denotes severe pneumonia; The presence of cyanosis, inability to drink/ breastfeed, grunting, level of consciousness using the AVPU scale less than A in addition to the aforementioned is classified as very severe pneumonia. Recommended management is intravascular Crystalline penicillin, gentamycin and oxygen for severe pneumonia, intravascular crystalline penicillin for severe pneumonia and oral amoxyl or cotrimaxole for pneumonia. These guidelines have been disseminated through the Emergency Triage And Treatment Plus (ETAT +) coursesheld since 2007. Implementation of guidelines into care has been shown to reduce case fatality from pneumonia by 36%. OBJECTIVES: To evaluate the level of adherence and factors affecting adherence to the National guidelines on management of pneumonia in children aged two to fifty nine months at Garissa provincial General Hospital, Kenya. DESIGN: Retrospective hospital based cross sectional study. SETTING: Paediatric Department of Garissa Provincial General Hospital (PGH) in Kenya. SUBJECTS: Hospital medical records of children aged two to fifty nine months diagnosed with pneumonia between January and June 2012 were reviewed. Data abstracted from the records included demographic information, recorded clinical signs and symptoms, disease classification and treatment. RESULTS: Records of 91 childrenwere reviewed. Theirmedian age was 12 months (IQR 6 - 18 months). There were more boys than girls with a male to female ratio of 1.25:1. Forty-eight of the participants (52.8%) had severe pneumonia. Guideline adherence was assessed at three levels; assessment of clinical signs and symptoms reflected by their recording, correct disease severity classification and correct treatment prescribed. There were a minimum of two and a maximum of six clinical sign and symptoms recorded. The average level of adherence was 42.9% (SD ± 17.3).Documented correct classification of disease severity was 56.6% and recommended treatment of pneumonia was 27.7%. The presence of a co-morbidity and severe disease was associated with better adherence to the assessment tasks (p = 0.033 and p = 0.021 respectively). Disease severity was associated with better adherence to the disease classification task (p = < 0.001) and treatment task (p = 0.02). CONCLUSION: Adherence to guidelines was low at all assessed levels. Overall, disease severity was associated with better guideline adherence. Presence of co-morbidities improved disease assessment.

CAREGIVERS' KNOWLEDGE AND HOME MANAGEMENT OF FEVER IN CHILDREN.

BACKGROUND: Fever is one of the most common complaints presented to the Paediatric Emergency Unit (PEU). It is a sign that there is an underlying pathologic process, the most common being infection. Many childhood illnesses are accompanied by fever, many of which are treated at home prior to presentation to hospital. Most febrile episodes are benign. Caregivers are the primary contacts to children with fever. Adequate caregivers' knowledge and proper management of fever at home leads to better management of febrile illnesses and reduces complications. OBJECTIVE: To determine the caregivers' knowledge and practices regarding fever in children. DESIGN: A cross-sectional study. SETTING: Peadiatric Emergency Unit at Kenyatta National Hospital (KNH) SUBJECTS: Two hundred and fifty caregivers of children under 12 years presenting with fever in August to October 2011 to the PEU. RESULTS: Three quarters of the caregivers' defined fever correctly. Their knowledge on the normal body was at 47.6%. Infection was cited as the leading cause of fever (95.2%). Brain damage (77.6%) and dehydration (65.6%) were viewed as the most common complication. Fever was treated at home by 97.2% of caregivers, most of them used medication. CONCLUSIONS: Fever was defined correctly by 75.2% of the study participants and a majority of them used touch to detect fever. Fever was managed at home with medications. Public Health Education should be implemented in order to enlighten caregivers on fever and advocate for the use of a clinical thermometer to monitor fever at home.

Multifocal pheochromocytoma in early childhood: case report.

A three and a half year old male with multifocal phaeochromocytoma involving the right adrenal gland and an intrathoracic mass is presented. Twenty four hour vanillylmandelic acid (VMA) was negative despite suggestive symptomatology. The diagnosis was made on serial CT scans of the head, thoracic inlet and pelvis. He underwent right adrenalectomy and thoracotomy to remove the abdominal and intrathoracic mass. The diagnosis was confirmed by histology. He remained hypertensive on hefty antihypertensive doses throughout his lifespan and finally succumbed to status epilepticus at the age of ten, six years from the time of diagnosis.

Effect of breastfeeding on mortality among HIV-1 infected women: a randomised trial.

BACKGROUND: We have completed a randomised clinical trial of breastfeeding and formula feeding to identify the frequency of breastmilk transmission of HIV-1 to infants. However, we also analysed data from this trial to examine the effect of breastfeeding on maternal death rates during 2 years after delivery. We report our findings from this secondary analysis. METHODS: Pregnant women attending four Nairobi city council clinics were offered HIVtests. At about 32 weeks' gestation, 425 HIV-1 seropositive women were randomly allocated to either breastfeed or formula feed their infants. After delivery, mother-infant pairs were followed up monthly during the first year and quarterly during the second year until death, or 2 years after delivery, or end of study. FINDINGS: Mortality among mothers was higher in the breastfeeding group than in the formula group (18 vs 6 deaths, log rank test, p=0.009). The cumulative probability of maternal death at 24 months after delivery was 10.5% in the breastfeeding group and 3.8% in the formula group (p=0.02). The relative risk of death for breastfeeding mothers versus formula feeding mothers was 3.2 (95% CI 1.3-8.1, p=0.01). The attributable risk of maternal death due to breastfeeding was 69%. There was an association between maternal death and subsequent infant death, even after infant HIV-1 infection status was controlled for (relative risk 7.9, 95% CI 3.3-18.6, p<0.001). INTERPRETATION: Our findings suggest that breastfeeding by HIV-1 infected women might result in adverse outcomes for both mother and infant.

Human resistance to Plasmodium falciparum increases during puberty and is predicted by dehydroepiandrosterone sulfate levels.

Immunity to Plasmodium falciparum develops slowly in areas of endemicity, and this is often ascribed to poorly immunogenic or highly variant parasite antigens. However, among populations newly exposed to malaria, adults acquire immunity more rapidly than children. We examined the relationship between pubertal development and resistance to P. falciparum. During two transmission seasons in western Kenya, we treated the same cohort of young males to eradicate P. falciparum and then obtained blood smears each week for 4 months. We determined pubertal development by Tanner staging and by levels of dehydroepiandrosterone sulfate (DHEAS) and testosterone in plasma. In multivariate and age-stratified analyses, we examined the effect of pubertal development on resistance to malaria. In both seasons (n = 248 and 144 volunteers, respectively), older males were less susceptible than younger males. Age-related decreases in the frequency and density of parasitemia were greatest during puberty (15- to 20-year-olds). DHEAS and testosterone were significant independent predictors of resistance to P. falciparum parasitemia, even after accounting for the effect of age. Fifteen- to 20-year-old males with high DHEAS levels had a 72% lower mean parasite density (P<0.01) than individuals with low DHEAS levels. Similarly, 21- to 35-year-old males with high DHEAS levels had a 92% lower mean parasite density (P<0.001) and 48% lower frequency of parasitemia (P<0.05) than individuals with low DHEAS levels. These data suggest that the long period needed to attain full immunity could be explained as a consequence of host development rather than as the requirement to recognize variant or poorly immunogenic parasite antigens.

Effect of breastfeeding and formula feeding on transmission of HIV-1: a randomized clinical trial.

CONTEXT: Transmission of human immunodeficiency virus type 1 (HIV-1) is known to occur through breastfeeding, but the magnitude of risk has not been precisely defined. Whether breast milk HIV-1 transmission risk exceeds the potential risk of formula-associated diarrheal mortality in developing countries is unknown. OBJECTIVES: To determine the frequency of breast milk transmission of HIV-1 and to compare mortality rates and HIV-1-free survival in breastfed and formula-fed infants. DESIGN AND SETTING: Randomized clinical trial conducted from November 1992 to July 1998 in antenatal clinics in Nairobi, Kenya, with a median follow-up period of 24 months. PARTICIPANTS: Of 425 HIV-1-seropositive, antiretroviral-naive pregnant women enrolled, 401 mother-infant pairs were included in the analysis of trial end points. INTERVENTIONS: Mother-infant pairs were randomized to breastfeeding (n = 212) vs formula feeding arms (n = 213). MAIN OUTCOME MEASURES: Infant HIV-1 infection and death during the first 2 years of life, compared between the 2 intervention groups. RESULTS: Compliance with the assigned feeding modality was 96% in the breastfeeding arm and 70% in the formula arm (P<.001). Median duration of breastfeeding was 17 months. Of the 401 infants included in the analysis, 94% were followed up to HIV-1 infection or mortality end points: 83% for the HIV-1 infection end point and 93% to the mortality end point. The cumulative probability of HIV-1 infection at 24 months was 36.7% (95% confidence interval [CI], 29.4%-44.0%) in the breastfeeding arm and 20.5% (95% CI, 14.0%-27.0%) in the formula arm (P = .001). The estimated rate of breast milk transmission was 16.2% (95% CI, 6.5%-25.9%). Forty-four percent of HIV-1 infection in the breastfeeding arm was attributable to breast milk. Most breast milk transmission occurred early, with 75% of the risk difference between the 2 arms occurring by 6 months, although transmission continued throughout the duration of exposure. The 2-year mortality rates in both arms were similar (breastfeeding arm, 24.4% [95% CI, 18.2%-30.7%] vs formula feeding arm, 20.0% [95% CI, 14.4%-25.6%]; P = .30). The rate of HIV-1-free survival at 2 years was significantly lower in the breastfeeding arm than in the formula feeding arm (58.0% vs 70.0%, respectively; P = .02). CONCLUSIONS: The frequency of breast milk transmission of HIV-1 was 16.2% in this randomized clinical trial, and the majority of infections occurred early during breastfeeding. The use of breast milk substitutes prevented 44% of infant infections and was associated with significantly improved HIV-1-free survival.

Effects of passive smoking and breastfeeding on childhood bronchial asthma.

OBJECTIVE: To evaluate the effect of passive smoking and breastfeeding on the severity and age of onset of bronchial asthma. DESIGN: Cross-sectional study. SETTING: Paediatric observation ward and paediatric chest clinic, Kenyatta National Hospital. PATIENTS: Children aged between one and 120 months. RESULTS: More than fifty per cent of the children had their first wheeze at less than 12 months of age and 68% were categorised as having moderate to severe asthma. Passive smoking was positively significantly associated with early onset of wheezing (chi 2 = 6.22, p = 0.012, Odds ratio = 2.44, 95% CI 1.2,5.0), and also, at a non significant level, to severity of asthma (chi 2 = 2.8, p = 0.09, Odds ratio = 2.1, 95% CI 0.9,4.7). On the other hand, exclusive breastfeeding was significantly negatively associated with severity of bronchial asthma (chi 2 = 4.02, p = 0.045, Odds ratio = 0.4, 95% CI 0.14,0.98), but did not seen to have effect on age of onset of the disease (chi 2 = 0.0006, p = 0.94, Odds ratio = 0.9, 95% CI 0.4,2.2). CONCLUSION: Passive smoking is associated with early onset of asthma and possibly with development of severe asthma while exclusive breastfeeding is protective against development of severe asthma but does not seem to affect the age of onset of this disease.

X-ray diagnosable pneumonia in children with severe malnutrition at Kenyatta National Hospital.

OBJECTIVES: To estimate the prevalence of radiologically evident pneumonia among children with severe malnutrition and to evaluate the diagnostic utility of commonly used clinical indicators of pneumonia among children with severe malnutrition. METHODS: All children with severe malnutrition and admitted at the then Paediatric Observation Ward without congestive cardiac failure, severe anaemia, or severe dehydration, were clinically evaluated and a posteroanterior chest X-ray taken for each child. Pneumonia was diagnosed on the basis of radiological changes consistent with pneumonia as reported by an experienced radiologist. The performance of the various clinical parameters as diagnostic tests for pneumonia were also evaluated. SETTING: Kenyatta National Hospital, a tertiary level teaching institution for the University of Nairobi. RESULTS: One hundred and seven children comprising 68 males and 39 females were recruited into the study. Of these children, 38 had kwashiorkor, 40 had marasmus, while 29 had marasmic kwashiorkor. Radiological evidence of pneumonia was found in 58% of children with kwashiorkor, 75% with marasmic kwashiorkor, and 82% with marasmus. All the commonly used clinical parameters performed poorly as diagnostic tests for pneumonia among children with severe malnutrition. CONCLUSION: Prevalence of pneumonia was very high among children with severe malnutrition. Available clinical parameters, singly or in combination, are poor diagnostic tools for pneumonia in children with severe malnutrition. It is advisable to treat children with severe malnutrition as if they had pneumonia, even in the absence of suggestive clinical signs.

Dose- and time-dependent relations between infective Anopheles inoculation and outcomes of Plasmodium falciparum parasitemia among children in western Kenya.

Blood-stage level Plasmodium falciparum infection (parasitemia density) is generally elevated prior to, or at the time of, clinical presentation of severe pediatric malaria episodes. Intensity of exposure to infective Anopheles mosquito bites is a suspected determinant of higher density parasitemia. Analyses of entomologic and parasitologic data collected in 1986-1987 were conducted to investigate whether the dose of infective bites predicted the incidence or degree of P. falciparum parasitemia in Kenyan children < 6 years old. At 21 consecutive 30-day intervals, a new cohort (n approximately 50 each) was enrolled, cured of malaria parasites, and monitored over 84 days for recurrent parasitemia. Outcomes included time to parasitemia, time to parasitemia > or = 5,000/microliter, and parasitemia density. Ecologic and individual-level analyses were conducted. The mean infective bite exposure experienced by each cohort was significantly associated with the incidence of parasitemia (age-adjusted r2 = 0.38, p = 0.022) and more strongly associated with the incidence of parasitemia > or = 5,000/microliter (age-adjusted r2 = 0.72, p < 0.001). The infective bite dose, analyzed as a time-dependent covariate, was associated with a 2.8 times higher rate of parasitemia > or = 5,000/microliter among children exposed to > or = 1 infective bite per day as compared with the referent (rate ratio (RR) = 2.82, 95% confidence interval (CI) 2.24-3.56). Cumulative infective bite exposure, exposure duration, and age were significant predictors of recurrent parasitemia density in multiple linear regression analyses. The results support the contention that reductions in P. falciparum transmission intensity, in the absence of complete elimination, will reduce higher level parasitemia among African children.

PIP: Elevated numbers of asexual erythrocytic-stage Plasmodium falciparum parasites in the peripheral blood circulation is a known risk factor of the clinical severity of malaria episodes. The interrelationships among a continuum of sporozoite dose, duration of exposure, age, level of parasitemia at enrollment, village of residence, sex, and recurrent P. falciparum parasitemia were investigated in a 2-year (1986-87) study of 862 children 6 months to 6 years of age from six contiguous villages in Western Kenya. At 21 consecutive 30-day intervals, a new cohort was enrolled, cured, and monitored over 84 days for recurrent parasitemia. The mean cumulative dose was 23 inoculations, and there was a significant linear correlation between this variable and the incidence rate of first recurrent parasitemia, with even stronger associations for the incidence of higher density parasitemia. The overall 70-day cumulative incidence of first recurrent parasitemia was 88.5% (22.5% for high-density P. falciparum). The infective bite dose, analyzed as a time-dependent covariate, was associated with a 2.8 times higher rate of parasitemia equal to or above 5000/mcl among children exposed to one or more bites per day compared to the referent. Each one unit increase in the mean dose was associated with a 24% higher rate of recurrent parasitemia and a 26% higher rate of recurrent high-density parasitemia after adjustment for covariates. Multiple linear regression analyses indicated that parasitemia density was significantly positively associated with cumulative dose and inversely associated with duration of exposure and age. Approximately 36% of the variance in malaria incidence rates was explained by the mean cumulative dose of infective bites.

Plasmodium falciparum gametocytemia in Kenyan children: associations among age, intensity of exposure to transmission, and prevalence and density of subsequent gametocytemia.

Recently, an association was described between the density of Plasmodium falciparum asexual parasitemia in Kenyan children and the entomologic inoculation rate (EIR) measured prior to measurement of asexual parasitemia. This study examined whether transmission pressure, as represented by the EIR, was associated with the prevalence or density of gametocytemia in Kenyan children. Each month for 19 months, a cohort of approximately 50 children was given a radical cure and enrolled in the study. Blood films were taken on days 0, 7, and 14. The EIR was calculated for the 28-day period ending 14 days prior to enrollment: the relationship between blood film data from day 7 and exposure variables was explored. We found that younger children were more likely to be gametocytemic than older children and, if gametocytemic, were more likely to have a dense gametocytemia. There was an inverse relationship between the number of infective bites per night received and prevalence but not density of gametocytemia, even after age adjustment. Concordance of gametocytemia prevalence on days 0 (64%), 7 (66%), and 14 (52%) was poor; 84% of the children were positive on at least one day. This indicates that in many subjects the detectable gametocytemia varied over the 14 days. Under these holoendemic transmission conditions, the EIR is inversely correlated with prevalence of gametocytemia, and point measurements of gametocytemia by conventional microscopy underestimate the number of infective donor hosts.

Genital shedding of human immunodeficiency virus type 1 DNA during pregnancy: association with immunosuppression, abnormal cervical or vaginal discharge, and severe vitamin A deficiency.

The presence of human immunodeficiency virus type 1 (HIV-1) in genital secretions may be a determinant of vertical HIV-1 transmission. Cervical and vaginal secretions from HIV-1-seropositive pregnant women were evaluated to determine prevalence and correlates of HIV-1-infected cells in the genital tract. HIV-1 DNA was detected by polymerase chain reaction in 32% of 212 cervical and 10% of 215 vaginal specimens. Presence of HIV-1 DNA in the cervix was associated with cervical mucopus and a significantly lower absolute CD4 cell count (354 vs. 469, P < .001). An absolute CD4 cell count <200 was associated with a 9.6-fold increased odds of cervical HIV-1 DNA detection compared with a count > or = 500 (95% confidence interval, 2.8-34.2). Detection of vaginal HIV- 1 DNA was associated with abnormal vaginal discharge, lower absolute CD4 cell count, and severe vitamin A deficiency. Presence of HIV-1-infected cells in genital secretions was associated with immunosuppression and abnormal cervical or vaginal discharge.

Human immunodeficiency virus type 1-infected cells in breast milk: association with immunosuppression and vitamin A deficiency.

Breast milk samples from human immunodeficiency virus type 1 (HIV-1)-seropositive women were analyzed by polymerase chain reaction to determine the prevalence and determinants of HIV-1-infected cells in breast milk. Breast milk samples (212) were collected from 107 women, and 58% of the samples had detectable HIV-1 DNA. The proportion of HIV-1-infected cells in the milk samples ranged from 1 to 3255/10(4) cells. Breast milk samples with detectable HIV-1 DNA were more likely to be from women with absolute CD4 cell counts of < 400 (odds ratio, 3.1; 95% confidence interval [CI], 1.5-7.0). Severe vitamin A deficiency (< 20 micrograms/dL) was associated with a 20-fold increased risk of having HIV-1 DNA in breast milk among women with < 400 CD4 cells/mm3 (95% CI, 2.1-188.5). Women with CD4 cell depletion, especially those with vitamin A deficiency, may be at increased risk of transmitting HIV-1 to their infants through breast milk.

Efficacy of halofantrine in the treatment of uncomplicated falciparum malaria.

In the last decade, Plasmodium falciparum resistance to a number of commonly used anti-malarials especially chloroquine, has increased considerably. Newer anti-malarial drugs are therefore being aggressively evaluated as alternatives. A randomized double-blind controlled trial was therefore undertaken, to compare the efficacy of halofantrine to that of metakelfin, in the treatment of moderately severe infections of Plasmodium falciparum in an endemic malaria area in Kenya. Three hundred and thirty five subjects with laboratory confirmed malaria were recruited and randomized to receive treatment with either halofantrine (171 subjects) or metakelfin (164 subjects). Two thirds (66%) of the study subjects were under the age of five years, and were therefore considered to have minimal immunity. All study subjects were initially admitted to hospital for three days and then followed up as out-patients on days 7, 14, 21, and 28. The level of parasitaemia, the presence of fever and the occurrence of adverse effects were evaluated. Halofantrine was found to be comparable to metakelfin in terms of resolution of fever (mean time 45 and 51 hours respectively). No major adverse side effects were observed. Halofantrine is a viable drug in the treatment of uncomplicated P. falciparum malaria.

Prevalence of persistent diarrhoea in children aged 3-36 months at the Kenyatta National Hospital, Nairobi, Kenya.

Three hundred and eighty four children aged 3-36 months admitted to the Infectious Diseases Hospital (IDH) with diarrhoea were studied for persistent diarrhoea (PD), defined as diarrhoea lasting more than 14 days. To establish the duration of diarrhoea, the children were evaluated daily while in hospital and on days seven, fourteen, twenty one and twenty eight of the diarrhoea episode, if discharged. Of these children, 268 (69.8%) were less than 12 months. There was a slight male preponderance with a male to female ratio of 1.2:1. Twenty (5.4%) children presented with diarrhoea of more than 14 days at admission while of the 364 who presented with diarrhoea of less than 14 days at admission, 40 (11%) developed persistent diarrhoea, giving a total PD rate of 16.5%. The peak age for PD was nine months with no sex difference. Some possible risk factors for PD were identified as blood in stools, pneumonia, malnutrition, not breastfeeding, severe dehydration and antibiotic treatment. The total number of deaths in the study cases was 50, giving a case fatality rate of 13.6%. Of the children with PD, 19(31.7%) died. The children with PD were at a four times greater risk of dying (P<0.001, OR = 4.16). This study indicates that prevalence of PD among children admitted to IDH is high; and carries a high case fatality.

Impact of transmission intensity and age on Plasmodium falciparum density and associated fever: implications for malaria vaccine trial design.

To facilitate design of vaccine trials, malaria was studied in 6-month- to 6-year-old Kenyans during high (HI) and low intensity transmission seasons. During 84 days after cure, exposure to infected mosquitoes was 9-fold greater in the HI group, yet incidence of P. falciparum infection was increased only 2-fold, with no age effect. The density of recurrent P. falciparum was 14-fold greater in the HI group, and there was a striking association between age and parasitemia > or = 5000/microL. Fever was the only clinical manifestation attributable to parasitemia and only when the parasite density was > or = 5000/microL. Sixty-four percent of children with > or = 20,000 parasites/microL versus 10% with 1-4999/microL were febrile when parasitemic. Recurrent P. falciparum infection as a vaccine trial end point can be studied year-round among children < or = 6 years [corrected] in western Kenya. However, high-grade parasitemia (> or = 5000 or 20,000/microL) with or without elevated temperature will be optimally studied in the high transmission season among children < 2 years.

Plasmodium falciparum incidence relative to entomologic inoculation rates at a site proposed for testing malaria vaccines in western Kenya.

Relationships between Plasmodium falciparum incidence and entomologic inoculation rates (EIRs) were determined for a 21-month period in Saradidi, western Kenya, in preparation for malaria vaccine field trials. Children, ranging in age from six months to six years and treated to clear malaria parasites, were monitored daily for up to 12 weeks to detect new malaria infections. Overall, new P. falciparum infections were detected in 77% of 809 children. The percentage of children that developed infections per two-week period averaged 34.7%, ranging from 7.3% to 90.9%. Transmission by vector populations was detected in 86.4% (38 of 44) of the two-week periods, with daily EIRs averaging 0.75 infective bites per person. Periods of intense transmission during April to August, and from November to January, coincided with seasonal rains. Relationships between daily malaria attack rates and EIRs indicated that an average of only 7.5% (1 in 13) of the sporozoite inoculations produced new infections in children. Regression analysis demonstrated that EIRs accounted for 74% of the variation in attack rates. One of the components of the EIR, the human-biting rate, alone accounted for 68% of the variation in attack rates. Thus, measurements of either the EIR or the human-biting rate can be used to predict corresponding attack rates in children. These baseline epidemiologic studies indicate that the intense transmission patterns of P. falciparum in Saradidi will provide excellent conditions for evaluating malaria vaccine efficacy.

Characteristics related to the incidence and prevalence of acute respiratory tract infection in young children in Kenya.

Acute respiratory tract infection (ARI) in children is a prevalent condition that results in substantial morbidity and consumes large portions of health care resources in developing countries. We examined factors associated with the reported incidence and prevalence of ARI in a 3-year longitudinal study of 485 children < 5 years of age in rural Kenya. A large number of environmental factors, household and family characteristics, and child-specific factors were examined with use of multivariable methods. Few variables that may play a role in the incidence and prevalence of ARI (e.g., household tobacco use and weight z-score) were found to be related to such rates. Several factors related to ARI incidence and prevalence (e.g., mother's age, number of children, and community) were found to be associated with only mild ARI episodes. Evidence is presented to support the hypothesis that these factors are related to differential reporting of mild ARI episodes. The impact of such differential reporting on health care utilization and health education is discussed.

Hypoxaemia in young Kenyan children with acute lower respiratory infection.

OBJECTIVES: To determine the prevalence, clinical correlates, and outcome of hypoxaemia in acutely ill children with respiratory symptoms. DESIGN: Prospective observational study. SETTING: Paediatric casualty ward of a referral hospital at 1670 m altitude in Nairobi, Kenya. SUBJECTS: 256 Infants and children under 3 years of age with symptoms of respiratory infection. MAIN OUTCOME MEASURES: Prevalence of hypoxaemia, defined as arterial oxygen saturation < 90% determined by pulse oximetry, and condition of patient on the fifth day after admission. RESULTS: Over half (151) of the children were hypoxaemic, and short term mortality was 4.3 times greater in these children. In contrast, the relative risk of a fatal outcome in children with radiographic pneumonia was only 1.03 times that of children without radiographic pneumonia. A logistic regression model showed that in 3-11 month old infants a respiratory rate > or = 70/min, grunting, and retractions were the best independent clinical signs for the prediction of hypoxaemia. In the older children a respiratory rate of > or = 60/min was the single best clinical predictor of hypoxaemia. The presence of hypoxaemia predicted radiographic pneumonia with a sensitivity of 71% and specificity of 55%. CONCLUSIONS: Over half the children presenting to this referral hospital with respiratory symptoms were hypoxaemic. A group of specific clinical signs seem useful in predicting hypoxaemia. The clear association of hypoxaemia with mortality suggests that the detection and effective treatment of hypoxaemia are important aspects of the clinical management of acute infections of the lower respiratory tract in children in hospital in developing regions.

PIP: In 1989, pediatricians followed 256 children 7 days to 36 months old with symptoms of respiratory infection at Kenyatta National Hospital (1670 m altitude) in Nairobi, Kenya. The symptoms were serious enough to warrant hospital admission for 209 of these children. The most common clinical diagnoses were pneumonia (53%) and bronchiolitis (33%). 59% of the children admitted to the hospital were hypoxemic (arterial oxygen saturation or + to 90%). 10% of all admitted children died. 90.4% of them were hypoxemic with arterial oxygen saturations ranging from 40-88%. Children with hypoxemia were 4.3 times more apt to die within 5 days than those with no hypoxemia (p = .02). On the other hand, children with radiographic pneumonia had a relative risk of short-term mortality of only 1.03. Hypoxemia on admission predicted short-term mortality with 90% sensitivity and 34% specificity. It predicted pneumonia with 71% sensitivity and 55% specificity (p .0001). Children who lived for at least 5 days had arterial oxygen saturations ranging from 41-98. Even though all of the children with clinically evident cyanosis were less than a year old, 89% of the hypoxemic infants less than 1 year old did not exhibit cyanosis. Mothers' reports of blueness in newborns and infants less than 2 months was the best predictor of hypoxemia (62% accuracy; p .05). For children 3-11 months old, the best predictors of hypoxemia, with an accuracy of 70%, were a respiratory rate of at least 70/minute (odds ratio [OR] 2.6; p .001). For children at least 12 months old, the sole best predictor was a respiratory rate of at least 60/minute (70% accuracy; OR 5.1; p .01). This study should be followed by well-designed studies of the clinical effectiveness of proper treatment with oxygen in preventing mortality in hypoxemic infants and children.

Recognition of illness in very young infants by inexperienced health workers.

To determine whether inexperienced health workers can recognize severe infection in infants less than 3 months of age, a study was conducted of 200 infants with cough, fever or 'not feeling well'. The presence or absence of five symptoms: cough, difficulty in breathing, feeding problem, fever or history of convulsions, and ten signs: appearing ill, respiratory rate > or = 60/min, chest indrawing, grunting, cyanosis, wheeze, lethargy, 'too hot', 'too cold' or abdominal distension, were recorded by a health worker, who made a diagnosis of 'ill' or 'mildly ill'. Each infant was then reviewed by an experienced paediatrician who made a diagnosis of 'ill' (pneumonia, sepsis, meningitis or other severe illness) or 'mildly ill'. Using these diagnoses as the 'gold standard', the sensitivity, specificity, and positive predictive values of each parameter were calculated. In 89% of the 200 infants, the health worker made the correct diagnosis. Forty infants were admitted. In 36 instances (90%) the health worker made the correct decision. The most discriminating symptoms and signs were 'not feeding well', 'appears ill', chest indrawing and grunting. A respiratory rate > or = 60/min was 78% sensitive and 69% specific. Our study suggests that inexperienced health workers can recognize severe illness in infants under 3 months of age.

Effect of vitamin A on diarrhoeal and respiratory complications of measles.

A randomized placebo-controlled trial of high dose vitamin A in acute measles was performed in Nairobi, Kenya to determine if it reduced the incidence or severity of diarrhoeal and respiratory complications. On enrollment laryngotracheobronchitis (LTB) pneumonia, diarrhoea and otitis media were each found in 45-80% of children in the treatment and placebo groups. While 4 of 119 cases of LTB in the placebo group progressed to grade III (loud stridor, markedly diminished air entry, chest indrawing, cyanosis), none of 116 in the vitamin A group did. Episodes of diarrhoea, but not pneumonia, resolved faster and were less severe in the vitamin A group. There were no differences in the incidences of pneumonia, LTB or diarrhoea during hospitalization, but children treated with vitamin A had a lower rate of developing otitis media. The overall case fatality rate was 2.7% and did not differ by group. These findings, along with those from three other trials in Africa, suggest that high dose vitamin A reduces the severity of complications during measles.