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BACKGROUND: Paediatric septic shock is a subset of sepsis associated with high mortality. Implementing the existing international Surviving Sepsis Campaign Guidelines 2012 (SSCG) have contributed to reduction of mortality in many places but these have not been adopted in our setting. The current study aimed at documenting the practice at a national referral hospital. METHODS: A hospital based longitudinal survey carried out among 325 children from September to October 2016. Children aged 0 days (≥37 weeks gestation) to12 years were included. The aim was to determine the prevalence, audit the management and determine the outcome at 72 hours of septic shock among children admitted at the Kenyatta National Hospital (KNH). A standard questionnaire was used for data collection and Surviving Sepsis Guideline 2012 was used as a reference for auditing the management of septic shock. Data was stored in MS-EXCEL and analysed in STATA 12. RESULTS: The prevalence of septic shock was 50 (15.4%), with a median age of 4 months. Septic shock was recognized by the attending clinician in 28 (56%). The level of care to children with septic shock was not to the level recommended by the SSCG 2012. Odds of being diagnosed with septic shock reduced with age (odds ratio 4.38 (1.7-11.0), p = 0.002) and no child aged above 60 months age was diagnosed with septic shock. The mortality was 35 (70%) at 72 hours of admission, with a median of 14 hours. Infants had the highest case fatality of 82.6%. It was found that lack of mechanical ventilation, and presence of hypotension at admission were associated with greater mortality (p values of 0.03 and 0.01 respectively). CONCLUSION: The prevalence rate of septic shock is 15.4% among children admitted at the KNH and is associated with high mortality. The advanced degree of shock contributed to mortality. The level of care at KNH was not to the level of SSCG 2012, and hence the need to include septic shock management guidelines/protocols in our local Kenyan paediatric guideline.
RESUMO
BACKGROUND: Exclusive breastfeeding (EBF) improves infant health and survival. We tested the effectiveness of a home-based intervention using Community Health Workers (CHWs) on EBF for six months in urban poor settings in Kenya. METHODS: We conducted a cluster-randomized controlled trial in Korogocho and Viwandani slums in Nairobi. We recruited pregnant women and followed them until the infant's first birthday. Fourteen community clusters were randomized to intervention or control arm. The intervention arm received home-based nutritional counselling during scheduled visits by CHWs trained to provide specific maternal infant and young child nutrition (MIYCN) messages and standard care. The control arm was visited by CHWs who were not trained in MIYCN and they provided standard care (which included aspects of ante-natal and post-natal care, family planning, water, sanitation and hygiene, delivery with skilled attendance, immunization and community nutrition). CHWs in both groups distributed similar information materials on MIYCN. Differences in EBF by intervention status were tested using chi square and logistic regression, employing intention-to-treat analysis. RESULTS: A total of 1110 mother-child pairs were involved, about half in each arm. At baseline, demographic and socioeconomic factors were similar between the two arms. The rates of EBF for 6 months increased from 2% pre-intervention to 55.2% (95% CI 50.4-59.9) in the intervention group and 54.6% (95% CI 50.0-59.1) in the control group. The adjusted odds of EBF (after adjusting for baseline characteristics) were slightly higher in the intervention arm compared to the control arm but not significantly different: for 0-2 months (OR 1.27, 95% CI 0.55 to 2.96; p = 0.550); 0-4 months (OR 1.15; 95% CI 0.54 to 2.42; p = 0.696), and 0-6 months (OR 1.11, 95% CI 0.61 to 2.02; p = 0.718). CONCLUSIONS: EBF for six months significantly increased in both arms indicating potential effectiveness of using CHWs to provide home-based counselling to mothers. The lack of any difference in EBF rates in the two groups suggests potential contamination of the control arm by information reserved for the intervention arm. Nevertheless, this study indicates a great potential for use of CHWs when they are incentivized and monitored as an effective model of promotion of EBF, particularly in urban poor settings. Given the equivalence of the results in both arms, the study suggests that the basic nutritional training given to CHWs in the basic primary health care training, and/or provision of information materials may be adequate in improving EBF rates in communities. However, further investigations on this may be needed. One contribution of these findings to implementation science is the difficulty in finding an appropriate counterfactual for community-based educational interventions. TRIAL REGISTRATION: ISRCTN ISRCTN83692672 . Registered 11 November 2012. Retrospectively registered.