Screening for developmental delay in urban Rwandan children: a cross sectional study.

BACKGROUND: Systematic or targeted screening for developmental delay (DD) is critical to the early identification of developmental disabilities. With limited available information for urban Rwandan children, this study aimed to determine the prevalence of DD and associated risk factors in infants aged 9 to 16 months living in the urban Rwandan city of Kigali. METHODS: A cross-sectional study was conducted in Rwanda from August to November 2019. A convenience sample of 376 Rwandan parents/caregivers and their children attending urban health centers for their routine immunization visits at 9 and 15 months of age was studied. Parents/caregivers completed the official Kinyarwandan version of the Ages and Stages Questionnaire (ASQ-3) and established cutoffs were used to identify DD. Frequency and percentages were used to summarise the data. Logistic regression analysis was used to identify factors associated with DD. RESULTS: Of the 358 children screened using the ASQ-3, the overall prevalence of DD was 24.6%, with a 27.2% prevalence among 9-10-month old children and 22.4% prevalence among 15-16-month old children. Delays in the combined group among the domains of gross motor, communication, fine motor, personal social, and problem solving were 12.8%, 2.5%, 8.4%, 1.7% and 7.5%, respectively. Gestational age at delivery and district of origin were most highly associated with DD, with preterm children at significantly higher risk of having DD compared to term children (Adjusted Odd Ratio AOR = 8.3; 95% CI = 2.5-27.4) and children from Nyarugenge District at high risk of DD compared to children from Gasabo district (AOR = 2.15; 95% CI = 1.2-3.9). CONCLUSIONS: The prevalence of ASQ-detectable DD among urban Rwandan children between 9 and 16 months of age was 24.6%, with a high correlation to a history of prematurity and district of origin. This study demonstrates the need for thoughtful health planning regarding integrated developmental surveillance for children, particularly those at high risk, to allow for earlier identification and intervention in the urban area of Kigali, Rwanda.

Prevalence, risk factors and outcomes of neonatal hypothermia at admission at a tertiary neonatal unit, Kigali, Rwanda - a cross-sectional study.

INTRODUCTION: Thermoregulation remains a key physiological challenge faced by a neonate after delivery. We assessed the prevalence, risk factors and outcomes of hypothermia in admitted neonates at a tertiary teaching hospital of Kigali city in Rwanda. MATERIALS AND METHODS: A cross-sectional study was conducted, from July 2013 to September 2017, of neonates who were admitted in the neonatology unit of the University Teaching Hospital of Kigali (CHUK) and whose admission temperature were recorded. Data were extracted from the neonatal database (registry). RESULTS: The neonatal database contained 1021 eligible neonates of which 15% were outborn. Hypothermia was found at admission in 280 of the 1021 eligible neonates (27%). The extremely preterm (<28 weeks) were significantly more likely to become hypothermic compared to term neonates (AOR = 6.81, CI: 3.39-13.71, p < .001). Mortality rate was higher in hypothermic infants (AOR = 1.89, CI: 1.16-3.1, p = .011). Length of hospital stay (22 versus 13 days, p < .001), in all surviving infants was higher in neonates admitted hypothermic, though not in the subgroups of infants < 32-week gestation. DISCUSSION: Thermal protection of the neonate immediately after birth is essential. In our tertiary neonatal unit, we identify nearly one-third of neonates are hypothermic at admission and this is associated with higher mortality and increased length of hospital stay. The ten-steps of the WHO "warm chain" may present an analytic roster for maternity and neonatal teams to pinpoint targets for interventional research and quality improvement work in order to achieve better outcomes.

The Effect of Circumcision on Exclusive Breastfeeding, Phototherapy, and Hospital Length of Stay in Term Breastfed Newborns.

BACKGROUND AND OBJECTIVES: Little is known about the effect of circumcision on breastfeeding in the hours and days after the procedure. Factors with the potential to negatively impact breastfeeding success in the newborn period may result in higher rates of jaundice requiring phototherapy and formula supplementation, both of which can potentially extend the length of initial hospitalization. Our objective was to determine the impact of circumcision on rates of exclusive breastfeeding, neonatal jaundice requiring phototherapy, and length of stay at hospital discharge immediately after birth. METHODS: Term male newborn infants whose mothers intended to exclusively breastfeed were included in this retrospective cohort. Bivariate analysis and multivariate logistic regression modeling were used to evaluate target behaviors, comparing infant boys who were circumcised with those who were uncircumcised. RESULTS: Of the 1109 breastfed male newborns included, 846 (76.6%) were circumcised. There was no significant effect of circumcision status or circumcision timing on the rate of in-hospital formula supplementation. There were no differences in peak bilirubin levels, phototherapy requirement, or length of hospital stay for male newborns based on circumcision status. CONCLUSIONS: Circumcision did not affect the rate of exclusive breastfeeding, neonatal jaundice, phototherapy requirement, or length of hospital stay in this retrospective analysis of breastfed male newborns.

Measuring change in knowledge acquisition of Rwandan residents: using the American Board of Pediatrics International In-Training Examination (I-ITE) as an independent tool to monitor individual and departmental improvements during the Human Resources for Health program: an observational study.

BACKGROUND: Rwanda is the only African country to use the pediatric International In-Training Examination (I-ITE). The objectives of this study were to use the scores from the I-ITE to outline the baseline level of knowledge of Rwandan residents entering the pediatric residency and the trends in knowledge acquisition from 2012 to 2018, during the Human Resources for Health (HRH) Program, an education partnership between the Rwanda Ministry of Health and a consortium of US universities. METHODS: A retrospective descriptive analysis of the I-ITE exam scores, taken by all Rwandan pediatric residents for five of the six academic years of the study period. Individual resident scores were weighted using the non-Rwandan I-ITE sites to minimise confounding from annual variations in exam difficulty. Statistical analysis included descriptives with ANOVA to compare variation in annual mean scores. RESULTS: Eighty-four residents took 213 I-ITE exam sittings over the five exam cycles. The mean weighted I-ITE score of all residents increased from 34% in 2013 to 49% (p < 0.001) in 2018. The 32-point gap between the mean US-ITE and Rwandan I-ITE score in 2012-2013 was reduced to a 16-point gap in 2017-2018. First year resident (PG1) scores, which likely reflect the knowledge level of undergraduate medical students entering the residency program, increased from 34.8 to 44.3% (p = 0.002) between 2013 and 2018. CONCLUSIONS: The I-ITE is an independent, robust tool, measuring both learners and the institutional factors supporting residents. This is the first study to demonstrate that the I-ITE can be used to monitor resident knowledge acquisition in resource-limited settings, where assessment of resident knowledge can be a major challenge facing the academic medicine community. The significant increase in I-ITE scores between 2012 and 18 reflects the substantial curricular reorganisation accomplished through collaboration between Rwandan and US embedded faculty and supports the theory that programs such as HRH are highly effective at improving the quality of residency programs and undergraduate medical education.

Establishing a neonatal database in a tertiary hospital in Rwanda - an observational study.

Background: Monitoring and evaluation is vital in the quest to improve the quality of care and to reduce the morbidity and mortality of neonates in a resource-limited setting. Databases offer several advantages such as data on large cohorts of neonates and from multiple centres. Aim: To establish a minimal dataset neonatal database in Kigali, Rwanda and to assess the quality and timing of the data entry process. Secondary objectives were to describe survival rates and associated risk factors. Methods: A cross-sectional, observational study was undertaken at a tertiary hospital in Kigali, Rwanda. The Rwanda Neonatal Data Collection Form was designed specifically for the database, based on the Vermont-Oxford Network neonatal data-collection tool with locally relevant amendments. All admitted neonates were enrolled during the study period of 2011-2017 with ongoing data-collection. Infants were recruited and data collected prospectively and cross-checked retrospectively with the inclusion of basic data on neonates who were not initially recruited prospectively. Results: 3391 analysable cases were recruited: 1420 prospective and 1971 retrospective cases. Prospective data collection peaked at 90%. Data entry was not always complete with data-points left blank with only 21% having adequate data available (0-25% missing). All-cause mortality during the study period was 16% and annual mortality ranged from 12% to 24%. On multivariate analysis, place of birth (AOR 2.17), small-for-gestational-age (AOR 2.05) and gestational age were all positively associated with survival. Conclusions: An academic setting in a low- or middle-income country can create and maintain a neonatal database without funding and produce a wealth of actionable results. Throughout the process, there were considerable challenges which must be addressed if such a database is to be optimised, maintained and created in other clinical sites. Abbreviations: CHUK: Centre Hospitalier et Universitaire de Kigali (University Teaching Hospital of Kigali); CPAP: continuous positive airway pressure; HCP: Healthcare professional; HRH, Human Resources for Health Programme; LMIC: low- and middle-income countries; MeSH: Medical subject headings; MoH: Ministry of Health; NAR: Newborn admission record; QI: Quality improvement; REDCap: Research electronic data capture; RNDB: Rwanda neonatal database; RNDCF: Rwanda neonatal data collecion form; SGA: Small for gestational age; STROBE: Strengthening the reporting of observational studies in epidemiology; VON: The Vermont-Oxford Network.

Global Health Education for Pediatric Residents: Trends, Training Experiences, and Career Choices.

: media-1vid110.1542/5849572022001PEDS-VA_2018-1559Video Abstract BACKGROUND AND OBJECTIVES: Knowledge and skills related to global child health are increasingly recognized as important to the practice of pediatrics. However, little is known about the status and trends in global health (GH) education in US pediatric residency programs. Our aim was to measure trends in residents' exposure to GH training, their GH education assessments, and GH career plans. METHODS: We analyzed GH-focused questions from national American Academy of Pediatrics surveys of graduating residents in 2008 and 2016. Logistic regression was used to estimate changes over time by using derived predicted values. RESULTS: A total of 1100 graduating pediatric residents participated; response rates were 58.8% for 2008 and 56.0% for 2016. The percentage of residents reporting that their programs offered GH training grew from 59.1% in 2008 to 73.1% in 2016 (P < .001). The majority were somewhat likely, very likely, or definitely planning to work or volunteer in a low- or middle-income country after their residency (predicted value of 70.3% in 2008 and 69.4% in 2016; P = .76). Fourteen percent of respondents reported having completed an international elective in 2016; of those, 36.5% did not receive formal preparation before the experience, and 24.3% did not participate in debriefing sessions on return. Overall, 27.3% of respondents in 2016 reported excellent (8.8%) or very good (18.5%) GH training. CONCLUSIONS: Although a substantial percentage of pediatric residents participate in international electives and plan to include GH activities in their careers, gaps remain, including suboptimal preparation and debriefing for GH electives.

Pediatricians and Global Health: Opportunities and Considerations for Meaningful Engagement.

Pediatric practitioners whose expertise is primarily focused on the care of children within health settings in the United States are increasingly engaged in global child health (GCH). The wide spectrum of this involvement may include incorporating short-term or longer-term GCH commitments in clinical care, teaching and training, mentoring, collaborative research, health policy, and advocacy into a pediatric career. We provide an overview of routes of engagement, identify resources, and describe important considerations for and challenges to better equipping US pediatric practitioners to participate in meaningful GCH experiences. This article is part of a series on GCH describing critical issues relevant to caring for children from an international perspective.

Global challenges, efforts, and controversies in neonatal care.

Simple low-cost, evidence-based interventions such as clean delivery practices, immediate warming, umbilical cord care, and neonatal resuscitation could prevent 40% to 70% of newborn deaths globally, but many obstacles preclude the provision of those basic interventions for all newborns, particularly in low-resource regions. Global efforts have led to widespread development of neonatal clinical practice guidelines, training programs, and policies. Because of a shortage of health care resources, standards of care have been redefined to meet the needs of underserved populations. This article provides an overview of the challenges, efforts, and controversies surrounding neonatal health in low-resource settings.

The effects of office-based frenotomy for anterior and posterior ankyloglossia on breastfeeding.

OBJECTIVES: The objectives of this study were to assess the effect of office-based frenotomy on reversing breastfeeding difficulties among infants with problematic ankyloglossia, and to examine characteristics associated with anterior and posterior ankyloglossia. METHODS: Mother's of infants who underwent a frenotomy for ankyloglossia from December 2006 through March 2011 completed a post-intervention web-based survey about breastfeeding difficulties they experienced before and after the frenotomy. Maternal-infant dyads had been referred from health providers to a primary care practice for assessment of ankyloglossia. Infants were subsequently classified as having no ankyloglossia, anterior (Type I or Type II) or posterior (Type III or Type IV). RESULTS: There were 311 infants evaluated for ankyloglossia and 299 (95%) underwent a frenotomy. Most infants were classified as having Type III (36%) or IV (49%) ankyloglossia compared to only 16% with anterior (Type I and Type II combined). Differences by classification type were found for gender (P=.016), age (P=.017), and maxillary tie (P=.005). Among survey respondents (n=157), infant latching significantly improved (P<.001) from pre- to post-intervention for infants with posterior ankyloglossia. Both the presence and severity of nipple pain decreased from pre- to post-intervention among all classifications (P<.001). Additionally, 92% of respondents breastfed exclusively post-intervention. The mean breastfeeding duration of 14 months did not differ significantly by classification. CONCLUSIONS: Breastfeeding difficulties associated with ankyloglossia in infants, particularly posterior, can be improved with a simple office-based procedure in most cases. The diagnosis and treatment of ankyloglossia should be a basic competency for all primary care providers and pediatric otorhinolaryngologists.

Global health education in U.S. medical schools.

Interest in global health (GH) among medical students worldwide is measurably increasing. There is a concomitant emphasis on emphasizing globally-relevant health professions education. Through a structured literature review, expert consensus recommendations, and contact with relevant professional organizations, we review the existing state of GH education in US medical schools for which data were available. Several recommendations from professional societies have been developed, along with a renewed emphasis on competencies in global health. The implementation of these recommendations was not observed as being uniform across medical schools, with variation noted in the presence of global health curricula. Recommendations for including GH in medical education are suggested, as well as ways to formalize GH curricula, while providing flexibility for innovation and adaptation.

A proposed model curriculum in global child health for pediatric residents.

OBJECTIVE: In response to the increasing engagement in global health (GH) among pediatric residents and faculty, academic GH training opportunities are growing rapidly in scale and number. However, consensus to guide residency programs regarding best practice guidelines or model curricula has not been established. We aimed to highlight critical components of well-established GH tracks and develop a model curriculum in GH for pediatric residency programs. METHODS: We identified 43 existing formal GH curricula offered by U.S. pediatric residency programs in April 2011 and selected 8 programs with GH tracks on the basis of our inclusion criteria. A working group composed of the directors of these GH tracks, medical educators, and trainees and faculty with GH experience collaborated to develop a consensus model curriculum, which included GH core topics, learning modalities, and approaches to evaluation within the framework of the competencies for residency education outlined by the Accreditation Council for Graduate Medical Education. RESULTS: Common curricular components among the identified GH tracks included didactics in various topics of global child health, domestic and international field experiences, completion of a scholarly project, and mentorship. The proposed model curriculum identifies strengths of established pediatric GH tracks and uses competency-based learning objectives. CONCLUSIONS: This proposed pediatric GH curriculum based on lessons learned by directors of established GH residency tracks will support residency programs in creating and sustaining successful programs in GH education. The curriculum can be adapted to fit the needs of various programs, depending on their resources and focus areas. Evaluation outcomes need to be standardized so that the impact of this curriculum can be effectively measured.

Global health education for pediatric residents: a national survey.

OBJECTIVE: To assess exposure to global health (GH) training, future plans to work or volunteer abroad, and the importance of GH training in program selection among graduating pediatric residents. METHODS: A national, random sample of graduating pediatric residents was surveyed in the 2008 American Academy of Pediatrics' Annual Graduating Residents Survey. Questions specific to GH training were included. RESULTS: The adjusted survey response rate was 59% (546 of 927); 534 residents from 170 programs responded to at least 1 GH question. GH training was an essential/very important factor in selecting a residency program for 22% of the respondents, and 21% reported participating in GH training during residency. In multivariate analyses, participation in GH training was associated with being single (adjusted odds ratio [aOR]: 1.90 [95% confidence interval (CI): 1.10-3.27]), graduating from a US medical school (aOR: 2.45 [95% CI: 1.14-5.28]), lower educational debt (aOR: 2.63 [95% CI: 1.54-4.49]), and training at a larger program (aOR: 2.73 [95% CI: 1.47-5.06]). One-third of respondents reported definite/very likely plans to work/volunteer in a developing country after residency; these respondents were more likely to be single (aOR: 1.82 [95% CI: 1.14-2.92]) and international medical school graduates (aOR: 2.10 [95% CI: 1.19-3.73]). Fewer than 50% of respondents received education in the majority of topics considered essential to GH training. CONCLUSIONS: GH-training opportunities are important to pediatric residents when selecting a program, and many are graduating with intentions to volunteer/work in a developing country after residency. The low exposure to GH topics among a broad cross-section of pediatric residents suggests that additional work is needed to adequately prepare pediatricians for work in GH after residency.