Potential effectiveness of integrating human milk banking and lactation support on neonatal outcomes at Pumwani Maternity Hospital, Kenya.

We assessed the potential effectiveness of human milk banking and lactation support on provision of human milk to neonates admitted in the newborn unit (NBU) at Pumwani Maternity Hospital, Kenya. This pre-post intervention study collected data from mothers/caregivers and their vulnerable neonates or term babies who lacked sufficient mother's milk for several reasons admitted in the NBU. The intervention included establishing a human milk bank and strengthening lactation support. Preintervention data were collected between 5 October 2018 and 11 November 2018, whereas postintervention data were collected between 4 September 2019 and 6 October 2019. Propensity score-matched analysis was performed to assess the effect of the intervention on exclusive use of human milk, use of human milk as the first feed, feeding intolerance and duration of NBU stay. The surveys included 123 and 116 newborns at preintervention and postintervention, respectively, with 160 newborns (80 in each group) being included in propensity score matched analysis. The proportion of neonates who exclusively used human milk during NBU stay increased from 41.3% preintervention to 63.8% postintervention (adjusted odds ratio [OR]: 2.68; 95% confidence interval [CI]: 1.31, 5.53) and those whose first feed was human milk increased from 55.0% preintervention to 83.3% postintervention (adjusted OR: 5.09; 95% CI: 2.18, 11.88). The mean duration of NBU stay was 27% (95% CI: 5.8%, 44.0%) lower in the postintervention group than in the preintervention group. The intervention did not affect feeding intolerance. Integrating human milk banking and lactation support may improve exclusive use of human milk among vulnerable neonates in a resource limited setting.

Clinical profile, etiology, and diagnostic challenges of primary adrenal insufficiency in Sudanese children: 14-years' experience from a resource limited setting.

OBJECTIVES: Primary adrenal insufficiency (PAI) in children is an uncommon condition. Congenital adrenal hyperplasia (CAH) is the commonest cause followed by autoimmune disorders. Diagnosis and management are challenging especially in resource-limited settings. Studies from Africa are scanty and here we describe for the first time the clinical presentation, possible etiologies, and challenges in diagnosis and management of PAI in a large cohort of Sudanese children. METHODS: This was a descriptive hospital-based study where all patients diagnosed with PAI between 2006 and 2020 were reviewed. The diagnosis was based on clinical presentation, low morning cortisol ± high adrenocorticotropic hormone (ACTH), or inadequate response of cortisol to synacthen stimulation. Challenges faced in diagnosis and management were identified. RESULTS: From 422 PAI suspected patients, 309 (73.2%) had CAH, and 33 (7.8%) had PAI-like symptoms and were not furtherly discussed. Eighty patients (19%) had fulfilled the study criteria: 29 had Allgrove syndrome, nine auto-immune polyendocrinopathy syndrome, seven adrenoleukodystrophy, and one had an adrenal hemorrhage. Hyperpigmentation was the cardinal feature in 75 (93.8%) while the adrenal crisis was not uncommon. Lack of diagnostic facilities has obscured the etiology in 34 (42.5%) patients. CONCLUSIONS: PAI is not uncommon in Sudanese children where genetic causes outweigh the autoimmune ones. Many cases were missed due to nonspecific presentation, lack of awareness, and difficult access to tertiary health care facilities. In addition to the clinical findings, early morning cortisol ± ACTH levels can be used in diagnosis where facilities are limited particularly synacthen stimulation test.

The paediatrician workforce and its role in addressing neonatal, child and adolescent healthcare in Kenya.

OBJECTIVE: To examine the availability of paediatricians in Kenya and plans for their development. DESIGN: Review of policies and data from multiple sources combined with local expert insight. SETTING: Kenya with a focus on the public, non-tertiary care sector as an example of a low-income and middle-income country aiming to improve the survival and long-term health of newborns, children and adolescents. RESULTS: There are 305 practising paediatricians, 1.33 per 100 000 individuals of the population aged <19 years which in total numbers approximately 25 million. Only 94 are in public sector, non-tertiary county hospitals. There is either no paediatrician at all or only one paediatrician in 21/47 Kenyan counties that are home to over a quarter of a million under 19 years of age. Government policy is to achieve employment of 1416 paediatricians in the public sector by 2030, however this remains aspirational as there is no comprehensive training or financing plan to reach this target and health workforce recruitment, financing and management is now devolved to 47 counties. The vast majority of paediatric care is therefore provided by non-specialist healthcare workers. DISCUSSION: The scale of the paediatric workforce challenge seriously undermines the ability of the Kenyan health system to deliver on the emerging survive, thrive and transform agenda that encompasses more complex health needs. Addressing this challenge may require innovative workforce solutions such as task-sharing, these may in turn require the role of paediatricians to be redefined. Professional paediatric communities in countries like Kenya could play a leadership role in developing such solutions.

Perceptions on donated human milk and human milk banking in Nairobi, Kenya.

Donor human milk (DHM) is recomended as the best alternative when use of mothers' own milk is not a feasible option. Kenya has not yet established human milk banks (HMBs) for provision of safe DHM, which is free from any physical, chemical, microbiological contaminants or pathogens. This study aimed to establish the perceptions on donating and using DHM, and establishing HMBs in Kenya. Qualitative data were collected through 17 focus group discussions, 29 key informant interviews, and 25 in-depth interviews, with women of childbearing age, community members, health workers, and policy makers. Quantitative interviews were conducted with 868 mothers of children younger than 3 years. Descriptive analysis of quantitative data was performed in STATA software, whereas qualitative interviews were coded using NVIVO and analysed thematically. Majority of them had a positive attitude towards donating breast milk to a HMB (80%) and feeding children on DHM (87%). At a personal level, participants were more willing to donate their milk to HMBs (78%) than using DHM for their own children (59%). The main concerns on donation and use of DHM were personal dislikes, fear of transmission of diseases including HIV, and hygiene concerns. Ensuring safety of DHM was considered important in enhancing acceptability of DHM and successful establishment of the HMBs. When establishing HMBs, Kenya must take into consideration communication strategies to address the main concerns raised regarding the quality and safety of the DHM. The findings will contribute to the development of HMB guidelines in Kenya and other African contexts.

Frequency and spectrum of outpatient musculoskeletal diagnoses at a pediatric hospital in Kenya.

Chronic pediatric musculoskeletal (MSK) conditions are a major cause of morbidity. The burden of pediatric rheumatic diseases in East Africa is largely unknown. The purposes of this study were to estimate frequencies and assess the spectrum of MSK-related diagnoses using ICD-10 diagnostic codes among outpatients at a pediatric hospital in Kenya and to evaluate the accuracy of the assigned codes used for the 'arthropathies' category. All pediatric outpatient diagnoses classified under the ICD-10 codes for 'diseases of the MSK system and connective tissue' (M00-M99) recorded between January and December 2011 were extracted from the electronic medical record system at Gertrude's Children's Hospital (GCH). For each of the ten MSK disease categories, frequencies were calculated. The assigned ICD10 code for cases in the 'arthropathies' (M00-M25) category was assessed by two rheumatologists. MSK diagnoses (n = 1078) accounted for 0.5% of all GCH outpatient consults available for analysis. 'Soft tissue disorders' were the most frequent MSK diagnoses (n = 614, 57%), followed by 'arthropathies' (n = 332, 30.8%), 'dorsopathies' (n = 81, 7.5%), 'osteopathies and chondropathies' (n = 39, 3.6%), and 'other' disorders (n = 12, 1.1%). No patients were classified in the category of 'systemic connective tissue disorders'. In cases classified as 'arthropathies', there was poor agreement (Kappa 0.136) between the ICD10 code assigned by the treating physicians and that assigned by the rheumatologists. However, when the rheumatologists' classification was loosened, agreement was moderate (Kappa 0.533). This study provides estimates of the frequency of outpatient MSK diagnoses at a pediatric hospital in Kenya in 2011. MSK diagnoses were not rare. Despite limitations of administrative databases to estimate frequencies of specific diagnoses, they provide a snapshot of the overall burden and spectrum of MSK conditions.

The spectrum of rheumatic in-patient diagnoses at a pediatric hospital in Kenya.

BACKGROUND: Pediatric rheumatic diseases are chronic illnesses that can cause considerable disease burden to children and their families. There is limited epidemiologic data on these diseases in East Africa. The aim of this study was to assess the spectrum of pediatric rheumatic diagnoses in an in-patient setting and determine the accuracy of ICD-10 codes in identifying these conditions. METHODS: Medical records from Gertrude's Children's Hospital in Kenya were reviewed for patients diagnosed with "diseases of the musculoskeletal system and connective tissue" as per ICD-10 diagnostic codes assigned at discharge between January and December 2011. Cases were classified as "rheumatic" or "non-rheumatic". Accuracy of the assigned ICD-10 code was ascertained. Death records were reviewed. Longitudinal follow-up of "rheumatic" cases was done by chart review up to March 2014. RESULTS: Twenty six patients were classified as having a "rheumatic" condition accounting for 0.32% of patients admitted. Of these, 11 (42.3%) had an acute inflammatory arthropathy, 6 (23.1%) had septic arthritis, 4 (15.4%) had Kawasaki disease, 2 (7.7%) had pyomyositis, and there was one case each of septic bursitis, rheumatic fever, and a non-specific soft tissue disorder. No cases of juvenile idiopathic arthritis (JIA) were identified. One case of systemic lupus erythematosus was documented by death records. The agreement between the treating physician's discharge diagnosis and medical records ICD-10 code assignment was good (Kappa: 0.769). On follow-up, one child had recurrent knee swelling that was suspicious for JIA. CONCLUSIONS: Pediatric rheumatic conditions represented 0.32% of admissions at a pediatric hospital in Kenya. Acute inflammatory arthropathies, septic arthritis and Kawasaki disease were the most frequent in-patient rheumatic diagnoses. Chronic pediatric rheumatic diseases were rare amongst this in-patient population. Despite limitations associated with the use of administrative diagnostic codes, they can be a first step in evaluating the spectrum of pediatric rheumatic conditions in Kenya and other countries in East Africa.

The Impact and Successes of a Paediatric Endocrinology Fellowship Program in Africa.

Background. The prevalence and distribution of endocrine disorders in children in Africa are not well known because most cases are often undiagnosed or diagnosed too late. The awareness of this led to the launch of the Paediatric Endocrinology Training Center for Africa (PETCA) designed to improve quality and access to health care by training paediatricians from Africa in paediatric endocrinology. Methods. The fellowship is undertaken over an 18-month period: six months of clinical and theoretical training in Kenya, nine months of project research at the fellow's home country, and three months of consolidation in Kenya. Upon completion, certified paediatricians are expected to set up centers of excellence. Results. There have been two phases, phase I from January 2008 to October 2012 and phase II from January 2012 to April 2015. Fifty-four fellows from 12 African countries have been certified, 34 (phase I) and 20 (phase II). Over 1,000 patients with wide ranging diabetes and endocrine disorders have been diagnosed and treated and are being followed up at the centers of excellence. Conclusion. The successes of the PETCA initiative demonstrate the impact a capacity building and knowledge transfer model can have on people in resource-poor settings using limited resources.

Glycemic Control in Kenyan Children and Adolescents with Type 1 Diabetes Mellitus.

Background. Type 1 diabetes mellitus (T1DM) is the most common endocrine disorder in children and adolescents worldwide. While data about prevalence, treatment, and complications are recorded in many countries, few data exist for Sub-Saharan Africa. The aim of this study was to determine the degree of control in patients with T1DM aged 1-19 years over a 6-month period in 3 outpatient Kenyan clinics. It also sought to determine how control was influenced by parameters of patient and treatment. Methods. Eighty-two children and adolescents with T1DM were included in the study. Clinical history regarding duration of illness, type and dose of insulin, and recent symptoms of hypoglycemia/hyperglycemia were recorded. Glycaemia, HbA1c, and ketonuria were tested. HbA1c of 8.0% and below was defined as the cut-off for acceptable control. Results. The median HbA1c for the study population was 11.1% (range: 6.3-18.8). Overall, only 28% of patients had reasonable glycemic control as defined in this study. 72% therefore had poor control. It was also found that age above 12 years was significantly associated with poor control. Conclusions. African children and with T1DM are poorly controlled particularly in adolescents. Our data strongly support the necessity of Kenya children to receive more aggressive management and follow-up.

Age at menarche in relation to nutritional status and critical life events among rural and urban secondary school girls in post-conflict northern Uganda.

BACKGROUND: Menarche age is an important indicator of reproductive health of a woman or a community. In industrial societies, age at menarche has been declining over the last 150 years with a secular trend, and similar trends have been reported in some developing countries. Menarche age is affected by genetic and environmental cues, including nutrition. The study was designed to determine the age at menarche and its relation to childhood critical life events and nutritional status in post-conflict northern Uganda. METHODS: This was a comparative cross-sectional study of rural and urban secondary school girls in northern Uganda. Structured questionnaires were administered to 274 secondary school girls, aged 12 - 18 years to determine the age at menarche in relation to home location, nutritional status, body composition and critical life events. RESULTS: The mean age at menarche was 13.6 ± 1.3 for rural and 13.3 ± 1.4 years for urban dwelling girls (t = -1.996, p = 0.047). Among the body composition measures, hip circumference was negatively correlated with the age at menarche (r = -0.109, p = 0.036), whereas height, BMI and waist circumference did not correlate with menarche. Paternal (but not maternal) education was associated with earlier menarche (F = 2.959, p = 0.033). Childhood critical life events were not associated with age at menarche. CONCLUSIONS: Age at menarche differed among urban and rural dwelling school girls and dependent on current nutritional status, as manifested by the hip circumference. It was not associated with extreme stressful childhood critical life events.

Behind the data: establishing the Network for Surveillance of Pneumococcal Disease in the East African Region.

In a region with high rates of mortality among children aged <5 years, the underfunded health care systems of sub-Saharan Africa have few resources available to perform surveillance activities that can help determine the causes of morbidity and mortality in the region. At present, there are few examples of attempts to promote public health care surveillance that might inform current debates about how to expand and improve surveillance, particularly for bacterial diseases. Driven by this gap in knowledge, we attempted to explore the successes and failures of the Network for Surveillance of Pneumococcal Disease in the East African Region and to share the experiences of what are essentially nonresearch public-sector hospitals in East Africa, with the hopes that surveillance systems for other diseases, especially those that require complex diagnostic support, may be informed by these experiences. The state of services essential for surveillance and the measures taken to overcome any shortcomings are described, as is the progress made in improving clinical diagnosis, laboratory processing, and data management. For surveillance to play a role in public health care, ministries of health and associated institutions must own and push forward the surveillance agenda, with support from global partners, and take advantage of the developments that have been achieved within the institutions.