Access to Workplace Supports is Positively Associated with Exclusive Breastfeeding among Formally Employed Mothers in Kenya.

BACKGROUND: Mothers in low-income settings who work in agricultural employment are challenged to meet breastfeeding (BF) recommendations. Recent legislation in Kenya mandates maternity leave and workplace supports, yet the relation of these benefits with BF practices is poorly understood. OBJECTIVES: We evaluated the associations with workplace-provided BF supports and BF practices among formally employed mothers in Kenya. The availability of supports was hypothesized to be associated with a higher prevalence and greater odds of exclusive breastfeeding (EBF). METHODS: We conducted repeated cross-sectional surveys among formally employed mothers at 1-4 d and 6, 14, and 36 wk (to estimate 24 wk) postpartum in Naivasha, Kenya. We used logistic regression adjusted for maternal age, education, physical burden of work, HIV status, and income to evaluate associations between workplace supports and EBF practices. RESULTS: Among formally employed mothers (n = 564), those who used onsite workplace childcare were more likely to practice EBF than those who used community- or home-based childcare at both 6 wk (95.7% compared with 82.4%, P = 0.030) and 14 wk (60.6% compared with 22.2%, P < 0.001; adjusted OR: 5.11; 95% CI: 2.3, 11.7). Likewise, at 14 wk among mothers who currently used daycare centers, a higher proportion of mothers who visited daycare centers at or near workplaces practiced EBF (70.0%) than of those not visiting daycare centers (34.7%, P = 0.005). EBF prevalence was higher among mothers with access to workplace private lactation spaces than among mothers without such spaces (84.6% compared with 55.6%, P = 0.037), and among mothers who lived in workplace housing than those without onsite housing (adjusted OR: 2.06, 95% CI: 1.25, 3.41). CONCLUSIONS: Formally employed mothers in Kenya who have access to and use workplace-provided BF supports were more likely to practice EBF than mothers who lacked these supports. As the Kenya Health Act is implemented, lactation rooms, onsite housing and daycare, and transportation to visit children can all support BF and EBF among employed mothers.

Formal maternal employment is associated with lower odds of exclusive breastfeeding by 14 weeks postpartum: a cross-sectional survey in Naivasha, Kenya.

BACKGROUND: In many low- and middle-income countries, improvements in exclusive breastfeeding (EBF) have stalled, delaying reductions in child mortality. Maternal employment is a potential barrier to EBF. OBJECTIVES: We evaluated associations between maternal employment and breastfeeding (BF) status. We compared formally and non-formally employed mothers in Naivasha, Kenya, where commercial floriculture and hospitality industries employ many women. METHODS: We conducted a cross-sectional survey among mothers (n = 1186) from September 2018 to October 2019 at 4 postpartum time points: at hospital discharge (n = 296) and at 6 wk (n = 298), 14 wk (n = 295), and 36 wk (to estimate BF at 24 wk; n = 297) postpartum. Mothers reported their BF status and reasons for EBF cessation. We used multivariable logistic regression models to test the association between formal maternal employment and 3 outcomes: early BF initiation (within 1 h of birth), EBF at each time point, and continued BF at 9 mo. Models were informed by a directed acyclic graph: a causal diagram used to characterize the relationship among variables that influence the independent (employment) and dependent (BF status) variables. RESULTS: EBF did not differ by employment status at hospital discharge or at 6 wk postpartum. However, formally employed mothers were less likely than those not formally employed to report EBF at 14 wk (59.0% compared with 95.4%, respectively; AOR: 0.19; 95% CI: 0.10, 0.34) and at 24 wk (19.0% compared with 49.6%, respectively; AOR: 0.25; 95% CI: 0.14, 0.44). The prevalence of continued BF at 36 wk did not differ by group (98.1% for formally employed compared with 98.5% for non-formally employed women; AOR: 0.80; 95% CI: 0.10, 6.08). The primary reasons reported for early EBF cessation were returning to work (46.5%), introducing other foods based on the child's age (33.5%), or perceived milk insufficiency (13.7%). CONCLUSIONS: As more women engage in formal employment in low- and middle-income countries, additional supports to help prolong the period of EBF may be beneficial for formally employed mothers and their children.

Adherence to oral rehydration therapy among in-patient children aged 1-59 months with some or no dehydration.

OBJECTIVE: To determine adherence to oral rehydration solution (ORS) among in-patients aged 1-59 months suffering from gastroenteritis and having some dehydration (SD) or no dehydration (ND) in two rural hospitals in Kenya. METHODS: Children aged 1-59 months suffering from acute gastroenteritis with (SD) or (ND) were enrolled into the study, examined and medical records reviewed. On the second and third day of follow up, children were re-examined to ascertain hydration status and care-takers interviewed. RESULTS: Ninety-nine children were enrolled. Forty-five (75%) of the 60 children with SD received a correct prescription for ORS but only 12 (20%) received the correct amount. Among the 39 children with ND, 23 (59%) received a correct prescription for ORS, however only 16 (41%) received the correct amount. On the 3rd day, 9 (15%) of the 60 children with SD at baseline and 2 (5%) of the 39 with ND were classified as having SD. CONCLUSION: Four in five children with SD and 6 in 10 children with ND fail to receive the correct amounts of ORS.

Harlequin ichthyosis in an African child: case report.

Severe congenital skin abnormalities are a rare event. This case is unique in that it is a case of harlequin ichthyosis in sub-sahara Africa in a child of African origin and elaborates the challenges faced in its management. We present a neonate who was managed for this condition at Chogoria Mission Hospital. In presenting this case, we aim to sensitise healthcare providers to promptly recognise and manage this rare skin condition.

Risk factors for cardiac dysfunction in children on treatment for cancer at Kenyatta National Hospital, Nairobi.

OBJECTIVE: To determine the point prevalence of abnormal cardiac function and to assess the risk factors for cardiac dysfunction in paediatric oncology patients on treatment at Kenyatta National Hospital. DESIGN: Descriptive cross-sectional study with a nested case control. SETTING: Kenyatta National Hospital between February and April 2006. MAIN OUTCOME MEASURES: Left ventricular dysfunction if ejection fraction (EF) <55% or fractional shortening (FS) <29% defined cases. Controls had EF >55% or FS >29%. RESULTS: One hundred and eleven patients were enrolled of whom 32 had abnormal cardiac function and were classified as cases while 79 had normal cardiac function. About a third, point prevalence 29% (95% CI 21.2-37.9), had cardiac dysfunction. Cumulative anthracycline dose was a risk factor for cardiac dysfunction in this population. Above 200 mg/m2 the attributable risk percentage of cardiac dysfunction was 77%. CONCLUSIONS: Serial echocardiography should be performed to identify patients at risk. Alternative treatment protocols should be used when the cumulative anthracycline dose exceeds 200 mg/m2 due to the high attributable risk. Studies to further assess the other associated risk factors and long term effects of anthracycline are recommended.

Salivary human immunodeficiency virus (HIV)-1-specific immunoglobulin A in HIV-1-exposed infants in Kenya.

Humoral immunity, and specifically immunoglobulin A (IgA) that is directed against human immunodeficiency virus (HIV)-1, may contribute to protection against HIV-1 acquisition at mucosal surfaces. HIV-1-specific IgA has been detected in genital tract secretions of HIV-1-uninfected commercial sex workers with HIV-1 exposure, and may be produced in parotid saliva by infants exposed orally to HIV-1 during delivery and breastfeeding. To explore this hypothesis, we collected saliva from 145 infants aged < or = 6 months enrolled in a perinatal HIV-1 transmission study in Nairobi and from 55 control infants without HIV-1 exposure who were born to HIV-1-seronegative mothers. Among the 145 infants, 115 (79%) remained uninfected during the 12-month study period and 30 (21%) became HIV-1-infected during follow-up. Nine (8%) of the 115 HIV-1-exposed, uninfected infants had detectable levels of HIV-1 gp160-specific IgA compared with four (13%) of 30 infected infants and none of 55 control infants (P = 0.47 and P = 0.03 respectively). Among the nine HIV-1-exposed, uninfected infants with positive assays, median age was 1 month and none acquired HIV-1 during follow-up. We conclude that HIV-1-specific salivary IgA responses may be generated by very young infants exposed perinatally to maternal HIV-1. Mucosal responses would be an appropriate target for paediatric vaccines against breast milk HIV-1 transmission.

Contextualising the paediatric HIV epidemic: a review.

OBJECTIVE: To draw attention to the sub-optimal care that HIV-infected children are receiving in Africa. DATA SOURCES: Relevant published literature. DATA SYNTHESIS: Sub-optimal response to paediatric HIV infection has aggravated the negative impact that the epidemic has had on child health in Africa. Recently the African Network for the Care of Children Affected by HIV/AIDS (ANNECA) released an advocacy statement that called for the optimisation of prevention, diagnosis, treatment and care for children affected by the AIDS pandemic. Effective prevention strategies if comprehensively implemented, could prevent more than 500 000 paediatric infections per annum at current antenatal HIV prevalence rates. Improved care that includes universal utilisation of early diagnostic testing systems, cotrimoxazole prophylaxis, nutritional support and the timely introduction of antiretroviral therapy could improve the quality of life and lifespan of most infected children. CONCLUSION: Political leaders, public health officials and fellow child health professionals are urged to redouble their efforts to reverse the magnitude of the paediatric epidemic in Africa.

Prevention of mother-to-child transmission of HIV-1 in Africa.

PIP: With the prevalence of HIV among pregnant women higher than 35% in some parts of sub-Saharan Africa, the number of HIV-infected children will continue to grow. It is estimated that almost 70% of the approximately 500,000 children who became infected with HIV in 1995 were born in sub-Saharan Africa. An effective intervention to prevent the vertical transmission of HIV is therefore most urgently needed in Africa. Following the release of the results of the AIDS Clinical Trials Group (ACTG) 076 study, the routine use of zidovudine (AZT) among HIV-infected pregnant women in the US and Europe has resulted in a significant reduction in the rate of mother-to-child vertical HIV transmission. However, most women in Africa will not benefit from these advances in the immediate future due to inadequate prenatal health care, the unavailability of prenatal HIV testing, and the high cost and complexity of the recommended regimen. Researchers need to build upon the findings of developed countries to identify feasible, effective, and implementable interventions to reduce the vertical transmission of HIV as well as to prevent HIV infection among women and to protect the health of HIV-infected women in Africa. Rates and timing of vertical HIV transmission, risk factors associated with vertical HIV transmission, and prevention interventions are discussed.^ieng

Sexual abuse of children as seen at Kenyatta National Hospital.

A retrospective study of 21 sexually abused children admitted to the Kenyatta National Hospital, Nairobi, Kenya, between January 1984 and December 1985 is presented. The peak incidence of sexual abuse was in the age group of 10-15 years (38.1%) followed by the 5-9 years age group (28.6%). Strangers and people familiar to the child were equally implicated as assailants. Fourteen out of the twenty one (66.7%) victims, presented with injuries ranging from perineal tears (19%), vaginal tears (19%), recto-vaginal fistulae (RVP) (4.8%) and vesico-vaginal-fistulae (VVF) and abdominal haematoma (4.8%). The victims presented to hospital within two days of the event usually accompanied by their mothers.

PIP: American studies report that 15% of reported child abuse case involve sexual abuse. Sexual abuse can be sexual molestation, sexual intercourse, and/or family related rape. Sexual abuse cases frequently come to the attention of hospital emergency care departments. Few reports appear in the medical literature on sexual abuse in Africa, although the media reports on its occurrence. This retrospective study provides information on the incidence and demographic characteristics of children admitted to Kenyatta National Hospital in Nairobi, Kenya, for sexual abuse. Records were obtained on rape or sexual abuse diagnosis cases between 1984 and 1988 for the following variables: age and sex of victim, time lapse before medical treatment, perpetrators relationship to victim, type of injury to victim, and person accompanying child to the hospital. The results reveal that 21 cases of children ranging from 4 months to 18 years were reported. In 19 cases, information on the assailant's character was unavailable. 66.7% of the victims were 5-15 years, and all were females. 15 (71.4%) were admitted within 2 days of the incident. 10 (47%) were sexually abused by strangers, and 11 (53%) by someone known such as a friend or relative. 19 incidents occurred after dark while on as parent-motivated errand. The place of victimization was usually close to the victim's home in cases where the assailant was known. The youngest children sustained the most severe injuries. Injuries included RVF and VVF, labial and perineal lacerations, hymenal tears, vaginal and perineal tears, abdominal injuries, and genital infection. Three children aged 4 6, and 7 showed evidence of previous coital experience. 5 children were without injuries. 19 patients stayed for 3 days or less; the other 2 with severe injuries stayed longer. 11 cases were brought by the mother. Case studies of the 4-month-old and the 9-year-old are presented. Discussion focuses on the nature of incestuous relationships and the character of the assailant. Prospective studies are needed, and prevention involves a massive public education effort.

Battered baby syndrome at Kenyatta National Hospital, Nairobi.

Thirty children presenting with Battered Baby Syndrome over a five year period were studied retrospectively. The male:female ratio was 1:1.1. The majority (60%) were aged 0-11 months. 14 children (46%) were abandoned while six (20%) had multiple fractures, six (20%) multiple bruises and bites, and four (13.3%) had other forms of abuse. Twelve (40%) children were malnourished while eight of the babies (26.6%) were small for gestational age. Children were most frequently brought to hospital by the police or their mothers. The children were most frequently abused by their mothers either through abandonment or through physical battering. Details of mothers of the 14 abandoned children were unknown. Among the mothers of the other children, nine mothers were single, seven married and living with spouses and one stepmother. Two children (6.6%) died while the fate of two others was not known. Three children were sent home without intervention of the social worker, while twenty three children were discharged following intervention of the social worker; fourteen sent home, nine to a childrens' home and one through the juvenile court.

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.

Mothers' knowledge, attitudes and practices regarding acute respiratory infections in children in Baringo District, Kenya.

BACKGROUND: Control of acute respiratory infections (ARI) is a major public health problem in developing countries. Implementation of case management protocols requires participation of the community to reduce morbidity and mortality from ARI. Health education programmes can only be effective when designed to take into account the prevailing knowledge, attitudes and practices (KAP) of the community towards ARI in their children. OBJECTIVE: To determine the KAP of mothers regarding ARI in their children aged less than five years. DESIGN: Community based cross-sectional survey. SETTING: Baringo District, Kenya. SUBJECTS: Mothers with children aged 0-5 years were recruited following stratified random sampling in three areas of Baringo District to represent low, medium and high potential areas based on agricultural productivity. INTERVENTION: A mixed structured and unstructured questionnaire was administered to each of the respondent mothers by the investigator; with the help of an interpreter where necessary. RESULTS: A total of 309 mothers were interviewed. Their mean age was 31.5 years (range 16-51) and 34% had no formal education. Only 18% of mothers described pneumonia satisfactorily. 60.2% knew that measles is preventable by immunisation. 87.1% of the mothers said they would seek health centre services for severe ARI. Formal education had a positive influence on the KAP of the mothers. CONCLUSION: The study reveals that the mothers had good knowledge of mild forms of ARI but not the severe forms. Their attitude to ARI was appropriate but subsequent practices were not. Low utilisation of health services for moderate ARI may result in continued high mortality because of delayed identification of seriously ill children.

Growth and development of abandoned babies in institutional care in Nairobi.

OBJECTIVE: To determine the pattern of growth and development of institutionalised infants and to compare the outcome with that of infants living with their biological mothers. DESIGN: A cross-sectional survey. SETTING: Seven children's homes; Kenyatta National Hospital's New Born Unit and Well Baby Clinics in Nairobi, Kenya. PARTICIPANTS: Eighty-two abandoned babies who fulfilled the selection criteria were recruited and for each abandoned baby two mothered babies matched for age and sex were selected from the well baby clinics. MAIN OUTCOME MEASURES: Anthropometric measures of weight, length, head circumference and left mid arm circumference (LUMAC) were taken and the mean values and Z scores determined to demonstrate growth pattern and nutritional status of the babies. The Revised Denver Development Screening Test (RDDST) was used to assess the development pattern of infants. RESULTS: Seventy per cent of infants were below six months old and 73% were abandoned within the first week of life. Abandoned babies were significantly thinner with the mean LUMAC of 10.8 cm versus 12.3 cm (p = 0.02) Institutionalised babies were significantly wasted (p = 0.00001) and stunted (p = 0.00001). Abandoned babies were significantly delayed in development (p < 0.0001). In all the four sectors tested for, institutionalised babies showed significant delay, p < 0.0001 in each sector. CONCLUSION: This study demonstrates that infants under institutional care have poorer growth and development compared to mothered infants.

PIP: This cross-sectional study examined the pattern of growth and development of infants in some of the baby institutions in Nairobi and compared the outcome with that of infants living with their biological mothers. The participating institutions included the Kenyatta National Hospital and 7 children's homes within the city. The study recruited 82 abandoned babies aged 1-18 months who had been abandoned for at least 2 weeks. Each abandoned baby was paired with 2 mothered babies matched for age and sex. Anthropometric measures of weight, length, head circumference, and left mid arm circumference (LUMAC) were taken. The mean values and Z scores were determined to assess growth pattern and nutritional status of the babies. The results showed that abandoned babies were significantly thinner, with a mean LUMAC of 10.8 cm vs. 12.3 cm. Moreover, abandoned babies were significantly wasted (p = 0.00001), stunted (p = 0.00001), and delayed in development (p 0.0001). These findings indicate that institutionalized infants have poorer growth and development compared to mothered infants.

Timing of breast milk HIV-1 transmission: a meta-analysis.

OBJECTIVE: To define the frequency and timing of breast milk transmission of HIV-1. DESIGN: Meta-analysis of data abstracted from published literature. SUBJECTS: Participants in prospective cohort studies of MTCT of HIV-1. Cohorts were separated on the basis of breast feeding duration. INTERVENTIONS: None. MAIN OUTCOME MEASURES: HIV-1 transmission rates. RESULTS: Two thousand three hundred and seventy five HIV-1 infected women and their infants, 499 of whom breast fed, the estimated risk of breast milk HIV-1 transmission was 16% (95% CI: 9, 22%). Among breastfeeding infants, forty seven per cent of HIV-1 infections were attributable to breast feeding. Breast milk transmission risk was 21% (95% CI: 10, 33%) in cohorts with mean/median duration of breast feeding > or = 3 months and 13% (95% CI: 4, 21%) in cohorts with median duration of breast feeding < 2 months. In a separate analysis of 702 infants with prolonged duration of breast feeding, the risk of late postnatal transmission (infection occurring later than three to six months of age) was four per cent (95% CI 2, 5%). CONCLUSIONS: This analysis suggests that breast milk transmission of HIV-1 is substantial and continues throughout the postnatal period. Early cessation of breast feeding at six months would avert some but not most infant HIV-1 infections due to breast feeding. While recently published studies showing some effectiveness of antiretrovirals early during the breast feeding period are encouraging, prevention of breast milk HIV-1 transmission needs to remain a high research priority.

HIV infection and sexual partnerships and behaviour among adolescent girls in Nairobi, Kenya.

Early sexual partnerships place young women in sub-Saharan Africa at high risk for HIV. Few studies have examined both individual- and partnership-level characteristics of sexual relationships among adolescent girls. A cross-sectional survey of sexual history and partnerships was conducted among 761 adolescent girls aged 15-19 years in Nairobi, Kenya. Rapid HIV testing was conducted and correlates of HIV infection were determined using multivariate logistic regression. The HIV prevalence was 7% and seropositive adolescents had a younger age at sexual debut (P < 0.01), more sexual partners in 12 months (P = 0.03), and were more likely to report transactional or non-consensual sex (P < 0.01). Girls who reported not knowing their partner's HIV status were 14 times as likely to be HIV-seropositive than girls who knew their partner's status (adjusted odds ratio: 14.2 [1.8, 109.3]). Public health messages to promote HIV testing and disclosure within partnerships could reduce sexual risk behaviours and HIV transmission among adolescents.