Clinical features to distinguish meningitis among young infants at a rural Kenyan hospital.

BACKGROUND: Detection of meningitis is essential to optimise the duration and choice of antimicrobial agents to limit mortality and sequelae. In low and middle-income countries most health facilities lack laboratory capacity and rely on clinical features to empirically treat meningitis. OBJECTIVE: We conducted a diagnostic validation study to investigate the performance of clinical features (fever, convulsions, irritability, bulging fontanel and temperature ≥39°C) and WHO-recommended signs (drowsiness, lethargy, unconsciousness, convulsions, bulging fontanel, irritability or a high-pitched cry) in discriminating meningitis in young infants. DESIGN: Retrospective cohort study. SETTING: Kilifi County Hospital. PATIENTS: Infants aged <60 days hospitalised between 2012 and 2016. MAIN OUTCOME MEASURE: Definite meningitis defined as positive cerebrospinal fluid (CSF) culture, microscopy or antigen test, or leucocytes ≥0.05 x 10∧9/L. RESULTS: Of 4809 infants aged <60 days included, 81 (1.7%) had definite meningitis. WHO-recommended signs had sensitivity of 58% (95% CI 47% to 69%) and specificity of 57% (95% CI 56% to 59%) for definite meningitis. Addition of history of fever improved sensitivity to 89% (95% CI 80% to 95%) but reduced specificity to 26% (95% CI 25% to 27%). Presence of ≥1 of 5 previously identified signs had sensitivity of 79% (95% CI 69% to 87%) and specificity of 51% (95% CI 50% to 53%). CONCLUSIONS: Despite a lower prevalence of definite meningitis, the performance of previously identified signs at admission in predicting meningitis was unchanged. Presence of history of fever improves the sensitivity of WHO-recommended signs but loses specificity. Careful evaluation, repeated assessment and capacity for lumbar puncture and CSF microscopy to exclude meningitis in most young infants with potential signs are essential to management in this age group.

Criteria for undernutrition screening in hospitalised infants under 6 months: a diagnostic accuracy study in a resource-poor setting.

PURPOSE: We aimed to describe the prevalence of undernutrition in hospitalised infants aged under 6 months and test the utility of simple index measures to detect undernutrition. DESIGN: Diagnostic accuracy study: weight, length, mid-upper arm circumference (MUAC), triceps and subscapular skinfolds were measured in infants aged 2 weeks to 6 months admitted to a Teaching Hospital in Enugu, Nigeria. Index criteria : low (<-2SD) weight-for-age Z-scores (WAZ), weight-for-length Z-scores (WLZ); MUAC <11 cm. Reference definition: weight faltering (conditional weight gain below fifth percentile for healthy Nigerian infants) or sum of skinfolds (SSF) <10 mm. RESULTS: Of 125 hospitalised infants, only 5% (6) were admitted specifically for undernutrition, but low SSF were found in 33% (41) and, 24% (25) with known birth weight had weight faltering, giving an undernutrition prevalence of 36%. Low WAZ was the most discriminating predictor of undernutrition (sensitivity 69%, positive predictive value 86%, likelihood ratio 5.5; area under receiver operator curves 0.90) followed by MUAC (73%, 73%, 4.9; 0.86), while WLZ performed least well (49%, 67%, 2.9; 0.84). Where both MUAC and WAZ were low, there was sensitivity 90%, positive predictive value 82% and likelihood ratio 8.7. CONCLUSIONS: Infants aged under 6 months admitted to hospital in Nigeria had a high prevalence of undernutrition. In young, high-risk population, a low WAZ alone was a valuable screening criterion, while combining weight with MUAC gave even higher discrimination. Measurement of length to calculate WLZ was a less useful predictor in this population.

Double burden of malnutrition among Indian schoolchildren and its measurement: a cross-sectional study in a single school.

OBJECTIVE: This cross-sectional study set in a single school on the outskirts of a large city aimed to document the extent of double burden of malnutrition (coexistence of overnutrition and undernutrition) among Indian schoolchildren from lower socioeconomic groups, and to determine if mid-upper arm circumference (MUAC) can be used as a proxy for body mass index (BMI). SUBJECTS: The total number of participants was 1444, comprising 424 girls and 1020 boys belonging to playgroups and grades 1 to 7. MEASUREMENTS: Anthropometric measurements, such as participants' MUAC, height and weight were measured using standard techniques. Descriptive statistics for BMI and MUAC were obtained based on gender; z-scores were computed using age-specific and sex-specific WHO reference data. The distribution of variables was calculated for three groups: girls, boys and all participants. Homogeneous subsets for BMI and MUAC were identified in the three groups. Age-wise comparisons of BMI and MUAC were conducted for each gender. MAIN OUTCOME MEASURES: (1) To know if MUAC and BMI are correlated among boys and girls. (2) To study BMI and MUAC z-score distribution among the participants. RESULTS: MUAC was positively correlated with BMI in both boys and girls. The following BMI z-score distribution was observed: severe acute malnutrition (SAM), 5 (0.3%); moderate acute malnutrition (MAM), 146 (10.1%) and undernourished, at risk of MAM/SAM, 141 (9.8%); obese, 21 (1.5%); overweight, 36 (2.5%) and pre-obese, 136 (9.4%). The distribution of categories of children based on MUAC z-scores was: SAM, 7 (0.5%); MAM, 181 (12.5%) and undernourished, at risk of MAM/SAM, 181 (12.5%); obese, 19 (1.3%); overweight, 178 (12.3%) and pre-obese, 135 (9.3%). CONCLUSIONS: SAM/MAM/undernourished states and obesity/overweight/pre-obese states, indicating undernutrition more than overweight, coexist among Indian schoolchildren from lower middle/lower socioeconomic categories. BMI and MUAC were significantly correlated. MUAC identifies both undernutrition and overnutrition by early detection of aberrant growth.

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.

Respiratory syncytial virus prevalence in children admitted to five Kenyan district hospitals: a cross-sectional study.

Acute respiratory infections (ARIs) are a leading cause of under-five mortality globally. In Kenya, the reported prevalence of respiratory syncytial virus (RSV) infections in single-centre studies has varied widely. Our study sought to determine the prevalence of RSV infection in children admitted with ARI fulfilling the WHO criteria for bronchiolitis. This was a prospective cross-sectional prevalence study in five hospitals across central and highland Kenya from April to June 2015. Two hundred and thirty-four participants were enrolled. The overall RSV positive rate was 8.1%, which is lower than in previous Kenyan studies. RSV-positive cases were on average 5 months younger than RSV-negative cases.

Prevalence and factors associated with the use of antibiotics in non-bloody diarrhoea in children under 5 years of age in sub-Saharan Africa.

OBJECTIVES: To estimate the prevalence and determine the factors associated with the use of antibiotics in the management of non-bloody diarrhoea in children under 5 years of age in sub-Saharan Africa (SSA). METHODS: We conducted a meta-analysis of demographic and health survey data sets from 30 countries in SSA. Pooled prevalence estimates were calculated using random effects model. Χ2 tests were employed to determine the factors associated with the antibiotic use. RESULTS: The pooled prevalence of antibiotic use among cases of non-bloody diarrhoea in children under 5 years of age was 23.1% (95% CI 19.5 to 26.7). The use of antibiotics in children with non-bloody diarrhoea in SSA was associated with (p<0.05) the source of care, place of residence, wealth index, maternal education and breastfeeding status. CONCLUSION: We found an unacceptably high use of antibiotics to treat episodes of non-bloody diarrhoea in children under the age of 5 in SSA.

Health needs of refugee children identified on arrival in reception countries: a systematic review and meta-analysis.

BACKGROUND: The worldwide number of refugees has considerably increased due to ongoing wars, national instability, political persecution and food insecurity. In Europe, about one-third of all refugees are children, an increasing number of which are travelling alone. There are often no systematic medical health assessments for these refugee children on entry in reception countries despite the fact that they are recognised as an at-risk population due to increased burden of physical and mental health conditions. We aimed to perform a systematic review of the literature to describe the health status of refugee children on entering reception countries. METHODS: A systematic search of published literature was conducted using the terms refugee, immigrant or migrant, medical or health, and screening. RESULTS: Of the 3487 potentially relevant papers, 53 population-based studies were included in this review. This systematic review showed that refugee children exhibit high estimated prevalence rates for anaemia (14%), haemoglobinopathies (4%), chronic hepatitis B (3%), latent tuberculosis infection (11%) and vitamin D deficiency (45%) on entry in reception countries. Approximately one-third of refugee children had intestinal infection. Nutritional problems ranged from wasting and stunting to obesity. CONCLUSIONS: Refugee children entering reception countries should receive comprehensive health assessments based on the outcomes of this systematic review, national budgets, cost-effectiveness and personal factors of the refugees. The health assessment should be tailored to individual child health needs depending on preflight, flight and postarrival conditions.A paradigm shift that places focus on child health and development will help this vulnerable group of children integrate into their new environments. PROSPERO REGISTRATION NUMBER: 122561.

Multiplex PCR reveals a high prevalence of multiple pathogens in traveller's diarrhoea in children.

OBJECTIVE: Traveller's diarrhoea (TD) is one of the most frequent illnesses affecting children returning from tropical countries. The purpose of this study was to assess the distribution of pathogens associated with TD in children using a multiplex PCR assay on stool samples. DESIGN: All the children admitted for TD in two university hospitals from 1 August to 15October during 2014 and 2015 were included in a prospective study. Stool samples were tested by a multiplex PCR FilmArray GI panel detecting 22 pathogens. Performances for the detection of major enteropathogenic bacteria (Salmonella, Shigella and Campylobacter spp) by multiplex PCR and conventional culture methods were compared. The prevalence of extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae was also determined. RESULTS: Fifty-nine children were included. In 58 cases (98%), at least one pathogen was identified, including 9 different enteropathogenic bacteria, 5 viruses and 2 parasites. Multiplex PCR enhanced the enteropathogenic bacteria detection by 25%. The most frequent pathogens were enteroaggregative Escherichia coli (n=32), enteropathogenic E. coli (n=26), enterotoxigenic E. coli (n=19), Salmonella enterica, enteroinvasive E. coli/Shigella (n=16 each), Cryptosporidium, sapovirus (n=11 each), Campylobacter jejuni, norovirus (n=10 each), rotavirus (n=9), Giardia (n=8) and Shiga-toxin-producing E. coli (n=4). Fifty-two coinfections were observed, notably including bacteria and viruses (n=21), multiple bacteria (n=14), or bacteria and parasites (n=10). ESBL were detected in 28 cases. Multiplex PCR could optimise the number of treated patients by 27% compared with stool cultures. CONCLUSION: Multiplex PCR on stools revealed a high prevalence of diverse enteric pathogens and coinfections in children with TD. Major enteropathogenic bacteria were more frequently detected by multiplex PCR compared with conventional culture. Finally, this technique allows the start of appropriate and early antibiotic treatment and seems to optimise the number of correctly treated patients.

Acquired heart disease in low-income and middle-income countries.

The burden of illness associated with acquired cardiac disease in children in low-income and middle-income countries (LMIC) is significant and may be equivalent to that of congenital heart disease. Rheumatic heart disease, endomyocardial fibrosis, cardiomyopathy (including HIV cardiomyopathy) and tuberculosis are the most important causes. All are associated with poverty with the neediest children having the least access to care. The associated mortality and morbidity is high. There is an urgent need to improve cardiac care in LMIC, particularly in sub-Saharan Africa and parts of Southeast Asia where the burden is highest.

Neonatal vaccination of low birthweight infants in Ghana.

OBJECTIVES: Global vaccination policy advocates for identifying and targeting groups who are underserved by vaccination to increase equity and uptake. We investigated whether birth weight and other factors are determinants of neonatal BCG vaccination in order to identify infants underserved by vaccination. METHODS: We used logistic regression to calculate adjusted ORs (AORs) for the association between birth weight (categorised as non-low birth weight (NLBW) (≥2.50 kg) and low birth weight (LBW) (2-2.49 kg, 1.50-1.99 kg and <1.50 kg)) and non-vaccination with BCG at the end of the neonatal period (0-27 days). We assessed whether this association varied by place of delivery and infant illness. We calculated how BCG timing and uptake would improve by ensuring the vaccination of all facility-born infants prior to discharge. RESULTS: There was a strong dose-response relationship between LBW and not receiving BCG in the neonatal period (p-trend<0.0001). Infants weighing 1.50-1.99 kg had odds of non-vaccination 1.6 times (AOR 1.64; 95% CI 1.30 to 2.08), and those weighing <1.50 kg 2.4 times (AOR 2.42; 95% CI 1.50 to 3.88) those of NLBW infants. Other determinants included place of delivery, distance to the health facility and socioeconomic status. Neither place of delivery nor infant illness modified the association between birth weight and vaccination (p-interaction all >0.19). Facility-born infants were vaccinated at a mean of 6 days, suggesting that they were not vaccinated in the facility at birth but were referred for vaccination. CONCLUSIONS: LBW is a risk factor for neonatal under-vaccination, even for facility-born infants. Ensuring vaccination at facility births would substantively improve timing and equitable BCG vaccination.

Neurodevelopmental outcomes for high-risk neonates in a low-resource setting.

Worldwide, most neonates who survive prematurity and serious illness reside in low-resource settings where developmental outcome data and follow-up care are limited. This study aimed to assess in Fiji, a low-resource Pacific setting, prevalence and risk factors for moderate to severe neurodevelopmental impairment (NDI) in early childhood among high-risk neonates compared with controls. Retrospective cohort study comparing long-term outcomes for high-risk neonatal intensive care unit patients (n=149) compared with matched term, normal birth weight neonates (n=147) discharged from Colonial War Memorial Hospital between November 2008 and April 2010. NDI was defined as one or more of cerebral palsy, moderate to severe hearing or visual impairment, or global developmental delay using Bayley Scales of Infant and Toddler Development Third Edition (ie, score <70 in ≥1 of cognitive, language or motor domains). At median (IQR) age 36.1 (28.3, 38.0) months, prevalence of moderate to severe NDI % (95% CI, n) in high-risk and control groups was 12 (5 to 17, n=13) and 5 (2 to 12, n=5), respectively, an increased risk ratio (95% CI) of 2.7 (0.8 to 8.9). Median gestational age (weeks (median, IQR)) in the high-risk group was 37.5 (34-40) weeks. Among high-risk neonates, gestational age, birth weight, asphyxia, meningitis and/or respiratory distress were significantly associated with risk of NDI. Prevalence of NDI was high among this predominantly term high-risk neonatal cohort compared with controls. Results, including identified risk factors, inform efforts to strengthen quality of care and models of follow-up for high-risk neonates in this low-resource setting.

Non-specific effects of vaccines: plausible and potentially important, but implications uncertain.

Non-specific effects (NSE) or heterologous effects of vaccines are proposed to explain observations in some studies that certain vaccines have an impact beyond the direct protection against infection with the specific pathogen for which the vaccines were designed. The importance and implications of such effects remain controversial. There are several known immunological mechanisms which could lead to NSE, since it is widely recognised that the generation of specific immunity is initiated by non-specific innate immune mechanisms that may also have wider effects on adaptive immune function. However, there are no published studies that demonstrate a mechanistic link between such immunological phenomena and clinically relevant NSE in humans. While it is highly plausible that some vaccines do have NSE, their magnitude and duration, and thus importance, remain uncertain. Although the WHO recently concluded that current evidence does not justify changes to immunisation policy, further studies of sufficient size and quality are needed to assess the importance of NSE for all-cause mortality. This could provide insights into vaccine immunobiology with important implications for infant health and survival.

Snake bite mortality in children: beyond bite to needle time.

OBJECTIVE: To study the clinical characteristics and predictors of mortality from snake bite envenomation in children. DESIGN: Prospective observational study with a one-group cohort design. SETTING: Paediatric intensive care unit of a tertiary care hospital in South India. SUBJECTS: The study cohort consisted of 145 children (55 girls and 90 boys) <12 years of age with snake bite envenomation. METHODS: Demographic and clinical details were recorded in a semistructured pro forma. Children were treated with polyvalent antisnake venom (ASV) as per WHO protocol. Details of treatment, complications and outcomes were recorded. Univariate analysis was done to identify statistical significance, and those variables found to be significant were analysed using binary logistic regression. RESULTS: Russell's viper was the most common offending snake followed by hump-nosed pit viper. Features of haemotoxicity, neurotoxicity and combined haemotoxicity and neurotoxicity occurred in 68 (47%), 39 (26.9%) and 9 (6%) children, respectively. Acute kidney injury (AKI) occurred in 36 (25%) children. The mortality rate was 10.3%. On univariate analysis, nocturnal bites, severe leucocytosis on day 1, AKI, capillary leak syndrome and a need for more than 20 vials of ASV were significantly associated with mortality. On multivariate analysis, only severe leucocytosis on day 1 (OR 35.29; 95% CI 1.37 to 911.89) and AKI (OR 35.05 95% CI 1.74 to 706.93) were found to be independent predictors of mortality. CONCLUSIONS: This study has identified two hitherto unrecognised risk factors-severe leucocytosis on day 1 and capillary leak syndrome. These findings need to be taken into consideration when planning management strategies for snake bite envenomation in children.

Setting up and running a paediatric emergency department in a hospital in Malawi: 15 years on.

Paediatric emergency care is not recognised as a specialty in many countries in Africa but is being practised increasingly. Setting up a paediatric emergency care unit takes time and often involves trial and error. Here we describe the start of the paediatric emergency department in Blantyre, Malawi, a low-income country and how it has continued to evolve over 15 years, in the hope that our experience will inform and assist others who are already developing their own emergency unit or wishing to do so.

Quality of life among children with spina bifida in Uganda.

BACKGROUND: Children surviving after spina bifida repair often have significant disability, the consequences of which may be more profound in low-income countries. The aim of this cross-sectional study was to measure quality of life (QOL) reported by children with spina bifida in Uganda, and to define factors associated with QOL. METHODS: QOL was measured using both the Health Utilities Index (HUI3) Tool and a visual analogue scale (VAS) marked from 0 to 10. In keeping with the WHO definition of QOL, further analysis was conducted using subjective QOL scores (using the VAS). Multivariate regression was used to investigate the association between VAS scores and prespecified variables: age, sex, hydrocephalus, mobility, urinary continence, school attendance and family size. RESULTS: Sixty two of 68 surviving children aged 10-14 were able to complete all aspects of the assessment. There was poor correlation between the VAS and HUI3 Tool (Pearson correlation 0.488). On multivariate regression, the following variables were associated with a significant change in the 10-point VAS (change in score; 95% CI): male sex (-1.45; -2.436 to -0.465), urinary continence (1.681; 0.190 to 3.172), large family size (-1.775; -2.773 to -0.777) and hydrocephalus (-1.382; -2.374 to -0.465). CONCLUSIONS: Urinary continence and family size are potentially modifiable, the former by simple and inexpensive medical management. Enhanced investment in community-based rehabilitation and support is urgently needed. Delivery of family planning services is a national priority in Uganda, and should be discussed with families as part of holistic care.

Developing guidelines in low-income and middle-income countries: lessons from Kenya.

There are few examples of sustained nationally organised, evidence-informed clinical guidelines development processes in Sub-Saharan Africa. We describe the evolution of efforts from 2005 to 2015 to support evidence-informed decision making to guide admission hospital care practices in Kenya. The approach to conduct reviews, present evidence, and structure and promote transparency of consensus-based procedures for making recommendations improved over four distinct rounds of policy making. Efforts to engage important voices extended from government and academia initially to include multiple professional associations, regulators and practitioners. More than 100 people have been engaged in the decision-making process; an increasing number outside the research team has contributed to the conduct of systematic reviews, and 31 clinical policy recommendations has been developed. Recommendations were incorporated into clinical guideline booklets that have been widely disseminated with a popular knowledge and skills training course. Both helped translate evidence into practice. We contend that these efforts have helped improve the use of evidence to inform policy. The systematic reviews, Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approaches and evidence to decision-making process are well understood by clinicians, and the process has helped create a broad community engaged in evidence translation together with a social or professional norm to use evidence in paediatric care in Kenya. Specific sustained efforts should be made to support capacity and evidence-based decision making in other African settings and clinical disciplines.

Improved oxygen systems in district hospitals in Lao PDR: a prospective field trial of the impact on outcomes for childhood pneumonia and equipment sustainability.

BACKGROUND: Hypoxaemia is a common and potentially fatal complication of many childhood, newborn and maternal conditions but often not well recognised or managed in settings where resources are limited. Oxygen itself is often inaccessible due to cost or logistics. This paper describes implementation of oxygen systems in Lao district hospitals, clinical outcomes after 24 months and equipment outcomes after 40 months postimplementation. METHODS: A prospective field trial was conducted in 20 district hospitals, including 10 intervention hospitals that received oxygen concentrators and 10 control hospitals. Equipment outcomes were evaluated at baseline, 12, 24 and 40 months. Clinical outcomes of children under 5 years of age with pneumonia were evaluated using a before-and-after controlled study design with information retrospectively collected from medical records. RESULTS: Fourteen (37%), 7 (18%) and 12 (34%) of 38 concentrators required repair at 12, 24 and 40 months, respectively. The proportion of children discharged well increased in intervention (90% (641/712) to 95.2% (658/691)) and control hospitals (87.1% (621/713) to 92.1% (588/606)). In intervention hospitals, case fatality rates for childhood pneumonia fell from 2.7% (19/712) preintervention to 0.80% (6/691) postintervention with no change in control hospitals (1.7% (12/713) preintervention and 2.3% (14/606) postintervention). CONCLUSION: Medium-term sustainability of oxygen concentrators in hospitals accompanied by reduced case fatality for childhood pneumonia has been demonstrated in Lao PDR. Significant local engineering capacity to address multiple causes of equipment malfunction was critical. The ongoing requirements and fragile structures within the health system remain major risks to long-term sustainability.

Medical and social issues of child refugees in Europe.

In mid-2015, there were an estimated 20.2 million refugees in the world; over half of them are children. Globally, this is the highest number of refugees moving across borders in 20 years. The rights of refugee children to access healthcare and be free from arbitrary detention are enshrined in law. Unaccompanied asylum-seeking children have a statutory medical assessment, but refugee children arriving with their families do not. Paediatricians assessing both unaccompanied and accompanied refugee children must be alert to the possibilities of nutritional deficiencies, infectious diseases, dental caries and mental health disorders and be aware of the national and international health guidance available for support.

Enhancing emergency care in low-income countries using mobile technology-based training tools.

In this paper, we discuss the role of mobile technology in developing training tools for health workers, with particular reference to low-income countries (LICs). The global and technological context is outlined, followed by a summary of approaches to using and evaluating mobile technology for learning in healthcare. Finally, recommendations are made for those developing and using such tools, based on current literature and the authors' involvement in the field.