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Vitamin A deficiency and soil‐transmitted helminth infection are serious public health problems in Kenya. The coverage of vitamin A supplementation and deworming medication (VASD) provided through mass campaigns is generally high, yet with a cost that is not sustainable, while coverage offered through routine health services is low. Alternative strategies are needed that achieve the recommended coverage of >80% of children twice annually and can be managed by health systems with limited resources. We undertook a study from September to December 2021 to compare the feasibility and coverage of VASD locally delivered by community health volunteers (CHV) ("intervention arm") to that achieved by the bi‐annual Malezi Bora campaign event ("control arm"). This comparative cross‐sectional study was conducted in sub‐counties of Siaya County using both qualitative and quantitative methods. VASD were offered through the CHS in Alego Usonga and through Malezi Bora in Bondo Sub‐County. Coverage was assessed by a post‐event coverage survey among caregivers of children aged 6–59 months (n = 307 intervention; n = 318 control). Key informant interviews were conducted with n = 43 personnel across both modalities, and 10 focus group discussions were conducted with caregivers of children aged 6–59 months to explore knowledge, attitudes and perceptions of the two strategies. VAS coverage by CHV was 90.6% [95% CI: 87.3–93.9] compared to 70.4% [95% CI: 65.4–75.4] through the Malezi Bora, while deworming coverage was 73.9% [95% CI: 69.0–78.7] and 54.7% [95% CI: 49.2–60.2], respectively. With sufficient training and oversight, CHV can achieve superior coverage to campaigns. Key messages: Innovative strategies are needed to effectively deliver vitamin A and deworming to eligible children through routine health services.Kenya's community health volunteers (CHVs) provide diverse preventive services, but do not distribute VASD.Our four month quasi‐experimental study in Siaya County utilized quantitative and qualitative methods to compare VASD added to the CHV package to the current bi‐annual Malezi Bora campaigns.VAS coverage by CHVs was higher at 90.6% [95% CI: 87.3–93.9] compared to Malezi Bora at 70.4% [95% CI: 65.4–75.4]; deworming coverage was 73.9% [95% CI: 69.0–78.7] vs. 54.7% [95% CI: 49.2–60.2], respectively.Success factors included effective incentives, comprehensive training, and strategic planning and regular review meetings at county and subcounty levels. [ABSTRACT FROM AUTHOR]

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. Key messages: Mother's milk is recommended for feeding preterm and low birthweight neonates.However, when the provision of mother's milk is not feasible, the use of donor human milk—from a human milk bank—is recommended.In this quasi‐experimental study, human milk banking and lactation support intervention increased the exclusive use of human milk during hospital stay and the use of human milk as the first feed among neonates admitted in the newborn unit at Pumwani Maternity Hospital, Kenya.The intervention also reduced the duration of stay in the newborn unit and there was no impact on feeding intolerance.Human milk banking and lactation support may improve the exclusive use of human milk among vulnerable neonates in a resource‐limited setting. [ABSTRACT FROM AUTHOR]

There is an urgent need for improved and timely health and nutrition data. We developed and tested a smartphone application that caregivers from a pastoral population used to measure, record and submit high‐frequency and longitudinal health and nutrition information on themselves and their children. The data were assessed by comparing caregiver‐submitted measurements of mid–upper arm circumference (MUAC) to several benchmark data sets, including data collected by community health volunteers from the participating caregivers during the project period and data generated by interpreting photographs of MUAC measurements submitted by all participants. We found that the caregivers participated frequently and consistently over the 12‐month period of the project; most of them made several measurements and submissions in at least 48 of the 52 weeks of the project. The evaluation of data quality was sensitive to which data set was used as the benchmark, but the results indicate that the errors in the caregivers' submissions were similar to that of enumerators in other studies. We then compare the costs of this alternative approach to data collection through more conventional methods, concluding that conventional methods can be more cost‐effective for large socioeconomic surveys that value the breadth of the survey over the frequency of data, while the alternative we tested is favoured for those with objectives that are better met by high‐frequency observations of a smaller number of well‐defined outcomes. Key messages: Caregivers, even those that are illiterate and with little smartphone experience, can and will use a simple icon‐based smartphone application to measure, record and submit health and nutrition information on themselves and their children consistently and at high frequency.The errors in the data submitted by the caregivers are similar to those of data submitted by enumerators in similar settings.The cost per data point of submissions by caregivers is much lower than data collected using conventional approaches but the simple icon‐ and audio‐based approach to data collection may not be appropriate for all data needs. [ABSTRACT FROM AUTHOR]

The southeastern region of Kenya is prone to aflatoxin outbreaks, yet maternal and infant aflatoxin intake levels remain unclear. We determined dietary aflatoxin exposure of 170 lactating mothers breastfeeding children aged 6 months and below in a descriptive cross‐sectional study involving aflatoxin analysis of maize‐based cooked food samples (n = 48). Their socioeconomic characteristics, food consumption patterns and postharvest handling of maize were determined. Aflatoxins were determined using high‐performance liquid chromatography and enzyme‐linked immunosorbent assay. Statistical analysis was conducted using Statistical Package Software for Social Sciences (SPSS version 27) and Palisade's @Risk software. About 46% of the mothers were from low‐income households, and 48.2% had not attained the basic level of education. A generally low dietary diversity was reported among 54.1% of lactating mothers. Food consumption pattern was skewed towards starchy staples. Approximately 50% never treated their maize, and at least 20% stored their maize in containers that promote aflatoxin contamination. Aflatoxin was detected in 85.4% of food samples. The mean of total aflatoxin was 97.8 μg/kg (standard deviation [SD], 57.7), while aflatoxin B1 was 9.0 μg/kg (SD, 7.7). The mean dietary intake of total aflatoxin and aflatoxin B1 was 7.6 μg/kg/b.w.t/day (SD, 7.5) and 0.6 (SD, 0.6), respectively. Dietary aflatoxin exposure of lactating mothers was high (margin of exposure < 10,000). Sociodemographic characteristics, food consumption patterns and postharvest handling of maize variably influenced dietary aflatoxin exposure of the mothers. The high prevalence and presence of aflatoxin in foods of lactating mothers are a public health concern and calls for the need to devise easy‐to‐use household food safety and monitoring measures in the study area. Key messages: A high prevalence of aflatoxin (84.4%) and high dietary aflatoxin exposure were reported among lactating mothers in the study.The mean concentration of 90% of maize‐based cooked food samples exceeded the 2 and 10 µg/kg set limits for aflatoxin B1 and total aflatoxin, respectively.Household size, education, socioeconomic status and limited food consumption patterns were potential determinants of dietary aflatoxin exposure in lactating mothers. Within dietary diversity, the type of food constituting a diverse diet played an important role.Postharvest handling of maize could be one of the factors contributing to dietary aflatoxin exposure in the study area.The reported results call for the need to devise easy‐to‐use household food safety and monitoring measures in the study area. [ABSTRACT FROM AUTHOR]

This implementation research study sought to examine the impact of the COVID-19 pandemic on maternal and infant nutrition practices, and related aspects of health and food systems in Nairobi and Uasin Gishu Counties, Kenya. The study triangulated in-depth interviews with 16 pregnant women, 31 lactating women (including COVID-19 positive), 10 facility health workers, 10 community health volunteers, 6 focus group discussions (FGDs) with food vendors, 4 FGDs and 15 stakeholder interviews with government and implementing partners. Trends from Kenyan Health Information System indicators (i.e., exclusive breastfeeding and initiation of breastfeeding, antenatal care) were also examined. During the COVID-19 pandemic, a decline in attendance of antenatal care, and maternity facilities was observed, and corroborated by Kenyan Health Information System data. Lack of clarity among health workers on COVID-19 breastfeeding guidance and fear of COVID-19 infection early in the pandemic were key drivers of early infant formula use, mother-child separation following delivery and delayed initiation of breastfeeding. Most women exclusively breastfed due to Government of Kenya restrictions in movement. Unemployment and job loss was linked to food insecurity and worsened by increased food prices and limited social protection measures. In response, pregnant and lactating women resorted to skipping meals and reducing quantity and variety of foods consumed. Efforts to build forward from COVID-19 in Kenya should include facility and community health education to prevent disruptions in breastfeeding and to support maternal dietary intake, and in the provision of targeted social protection measures alongside other multisectoral interventions (i.e., psychosocial support) for Kenyan pregnant and lactating women. [ABSTRACT FROM AUTHOR]

Grandmothers and fathers are key influencers of maternal and child nutrition and are increasingly included in interventions. Yet, there is limited research exploring their experiences participating in interventions. This study reports on findings from a qualitative process evaluation of a quasi‐experimental study that we conducted with grandmother and father peer dialogue groups to support maternal, infant and young child feeding practices in western Kenya. The aim was to explore grandmother and father experiences participating in interventions and how participation influences care and feeding practices. Grandmother and father peer educators received training to facilitate discussions about maternal and child nutrition, HIV and infant feeding, family communication, and family members' roles. Father peer educators also received training on gender inequities and power dynamics. In the original quasi‐experimental study, the intervention was associated with increased social support and improvements in some complementary feeding practices. The process evaluation explored participants' experiences and how participation influenced infant care and feeding practices. We used Atlas.ti to thematically analyse data from 18 focus group discussions. The focus group discussions revealed that grandmothers and fathers valued their groups, the topics discussed and what they learned. Grandmothers reported improved infant feeding and hygiene practices, and fathers reported increased involvement in child care and feeding and helping with household tasks. Both described improved relationships with daughters‐in‐law or wives. This study highlights the importance of engaging influential family members to support child nutrition and identifies factors to build cohesion among group members, by building on grandmothers' roles as advisors and expanding fathers' roles in nutrition through gender transformative activities. [ABSTRACT FROM AUTHOR]

Acute malnutrition in infants under 6 months (u6m) is increasingly recognised as a global public health problem. The World Health Organisation (WHO) guidelines for inpatient nutritional rehabilitation of infants u6m is re‐lactation: the re‐establishment of exclusive breastfeeding. Evidence suggests these guidelines are rarely followed in many low‐income settings. Two studies of infant nutritional rehabilitation undertaken in three public hospitals in coastal Kenya employed breastfeeding peer supporters (BFPSs) to facilitate WHO guideline implementation. To explore the acceptability of the strategy to health workers (HWs) and the BFPSs, in‐depth interviews were conducted with 20 HWs and five BFPSs in the three study hospitals. The HWs reported that the presence of the BFPSs changed the way infant nutritional rehabilitation was managed, increasing efforts at relactation and decreasing reliance on supplemental milk. BFPSs were said to help address staff shortages and had dedicated time to support and assist the mothers. Key to the success of the BFPSs was the social relationships they were able to establish with the mothers due to the similarity in their experiences and backgrounds. Despite the success of the BFPSs, human resource management and infrastructure challenges remained. BFPSs can successfully be employed to facilitate the implementation of the WHO guidelines for the nutritional rehabilitation of acutely malnourished infants u6m in hospitals in Kenya, establishing supportive social relationships and trust with the mothers of the acutely malnourished infants and helping to address the issue of human resource shortages. [ABSTRACT FROM AUTHOR]

Micronutrient deficiencies remain common among women and children in Sub‐Saharan Africa (SSA); in pregnant/lactating women, the intakes of essential fatty acids may also be low. Enriching home‐prepared foods with small‐quantity lipid‐based nutrient supplements (SQ‐LNSs) is a promising new strategy of delivering additional micronutrients, essential fatty acids and good quality protein to women and children. This narrative review aimed to examine the impact of SQ‐LNSs supplementation among women and infants and young children in SSA, and to discuss the differential impact of SQ‐LNS consumption across different settings. Papers reporting randomized trials conducted in SSA in which apparently healthy women and/or ≥6‐mo‐old children received SQ‐LNSs were identified through electronic and manual searches. Prenatal SQ‐LNS consumption reduced the prevalence of low gestational weight gain in Ghana when compared with multiple micronutrients supplementation, and was associated with poorer iron/hemoglobin status when compared with iron‐plus‐folic acid supplementation. SQ‐LNSs received alone or as intervention package improved infant/child growth in two trials in Ghana and one trial each in Burkina Faso, Kenya, Zimbabwe and South Africa, but had no impact on growth in two trials in Malawi. SQ‐LNSs supplementation improved motor development in Ghana, Burkina Faso, Malawi, Kenya, and South Africa, but had no impact on language, socio‐emotional, and executive functions in Ghana and Malawi and on Griffiths' developmental scores in Malawi. SQ‐LNSs may contribute to improving child growth in SSA. More research is needed to determine the iron level in SQ‐LNSs effective for improving both maternal hemoglobin/iron status and birth outcomes. [ABSTRACT FROM AUTHOR]

The Kenyan Ministry of Health has developed a National Strategy on Infant and Young Child Feeding with the goal of improving feeding practices for infants and children. In order to promote appropriate infant feeding, the government has explored implementation of the Baby Friendly Community Initiative (BFCI). This study assessed maternal knowledge of attributes of complementary feeding following implementation of BFCI in Koibatek, Kenya. A randomized control study composed of 270 mother–infant pairs previously enrolled in a BFCI programme in Koibatek was conducted. The study found that a significantly greater number of mothers in the intervention group were more knowledgeable about proper breastfeeding and complementary feeding aspects compared with controls (P ≤ 0.001). About half (53%) of mothers in the intervention group had high knowledge scores in comparison with 20% of mothers in the control group. When the relationship between mothers' knowledge and complementary feeding practices (minimum meal frequency, minimum dietary diversity and minimum acceptable diet) was assessed, significant associations were observed (P = 0.010, P ≤ 0.001 and P ≤ 0.001, respectively). The odds of having a high knowledge score regarding complementary feeding practices were significantly higher for the intervention group compared with the control group (odds ratio [OR]: 25.98, 95% confidence interval [CI] 13.62–49.55, P ≤ 0.001). The BFCI intervention effectively improved mothers' knowledge on complementary feeding and correlated with improved feeding practices. [ABSTRACT FROM AUTHOR]

This study aimed to examine the association between breastfeeding and childhood obesity. A multinational cross‐sectional study of 4,740 children aged 9–11 years was conducted from 12 countries. Infant breastfeeding was recalled by parents or legal guardians. Height, weight, waist circumference, and body fat were obtained using standardized methods. The overall prevalence of obesity, central obesity, and high body fat were 12.3%, 9.9%, and 8.1%, respectively. After adjustment for maternal age at delivery, body mass index (BMI), highest maternal education, history of gestational diabetes, gestational age, and child's age, sex, birth weight, unhealthy diet pattern scores, moderate‐to‐vigorous physical activity, sleeping, and sedentary time, exclusive breastfeeding was associated with lower odds of obesity (odds ratio [OR] 0.76, 95% confidence interval, CI [0.57, 1.00]) and high body fat (OR 0.60, 95% CI [0.43, 0.84]) compared with exclusive formula feeding. The multivariable‐adjusted ORs based on different breastfeeding durations (none, 1–6, 6–12, and > 12 months) were 1.00, 0.74, 0.70, and 0.60 for obesity (Ptrend =.020) and 1.00, 0.64, 047, and 0.64 for high body fat (Ptrend =.012), respectively. These associations were no longer significant after adjustment for maternal BMI. Breastfeeding may be a protective factor for obesity and high body fat in 9‐ to 11‐year‐old children from 12 countries. [ABSTRACT FROM AUTHOR]

The impact of quality complementary food products on infant growth and body composition has not been adequately investigated. This study evaluated the effect on fat‐free mass (FFM) accrual, linear growth, and iron status of locally produced complementary food products comparing to a standard product. In a randomized, double‐blind trial, 499 infants at 6 months received nine monthly rations of (a) WinFood Classic (WFC) comprising germinated amaranth (71%), maize (10.4%), small fish (3%), and edible termites (10%); (b) WinFood Lite (WFL) comprising germinated amaranth (82.5%), maize (10.2%), and multimicronutrient premix; or (c) fortified corn–soy blend plus (CSB+). Primary outcomes were changes in FFM, length, and plasma ferritin and transferrin receptors (TfR). FFM was determined using deuterium dilution. Analysis was by intention to treat, based on available cases. Compared with CSB+, there were no differences in change from 6 to 15 months in FFM for WFC 0.0 kg (95% CI [−0.30, 0.29]) and WFL 0.03 kg (95% CI [−0.25, 0.32]) and length change for WFC −0.3 cm (95% CI [−0.9, 0.4]) and WFL −0.3 cm (95% CI [−0.9, 0.3]). TfR increased in WFC group 3.3 mg L−1 (95% CI [1.7, 4.9]) and WFL group 1.7 mg L−1 (95% CI [0.1, 3.4]) compared with CSB+. Compared with the increase in Hb in CSB+ group, there was a reduction in Hb in WFC of −0.9 g dl−1 (95% CI [−1.3, −0.5]) and a lower increase in WFL −0.4 g dl−1 (95% CI [−0.8, 0.0]). In conclusion, the tested WinFoods had the same effect on FFM and length as CSB+, whereas Hb and iron status decreased, suggesting inhibited iron bioavailability from the amaranth‐based WinFoods. [ABSTRACT FROM AUTHOR]

Abstract: The effects of rickets on children recovery from severe acute malnutrition (SAM) are unknown. Rickets may affect both growth and susceptibility to infectious diseases. We investigated the associations of clinically diagnosed rickets with life‐threatening events and anthropometric recovery during 1 year following inpatient treatment for complicated SAM. This was a secondary analysis of clinical trial data among non‐human immunodeficiency virus‐infected Kenyan children with complicated SAM (2–59 months) followed for 1 year posthospital discharge ( ClinicalTrials.gov ID NCT00934492). The outcomes were mortality, hospital readmissions, and growth during 12 months. The main exposure was clinically diagnosed rickets at baseline. Of 1,778 children recruited, 230 (12.9%, 95% CI [11.4, 14 .6]) had clinical signs of rickets at baseline. Enrolment at an urban site, height‐for‐age and head circumference‐for‐age z scores were associated with rickets. Rickets at study enrolment was associated with increased mortality (adjusted Hazard Ratio [aHR] 1.61, 95% CI [1.14, 2.27]), any readmission (aHR 1.37, 95% CI [1.09, 1.72]), readmission for severe pneumonia (aHR 1.37, 95% CI [1.05, 1.79]), but not readmission with diarrhoea (aHR 1.05, 95% CI [0.73, 1.51]). Rickets was associated with increased height gain (centimetres), adjusted regression coefficient 0.19 (95% CI [0.10, 0.28]), but not changes in head circumference, mid‐upper arm circumference, or weight. Rickets was common among children with SAM at urban sites and associated with increased risks of severe pneumonia and death. Increased height gain may have resulted from vitamin D and calcium treatment. Future work should explore possibility of other concurrent micronutrient deficiencies and optimal treatment of rickets in this high‐risk population. [ABSTRACT FROM AUTHOR]

Abstract: This study examines the association between 3 dimensions of food insecurity (timing, intensity, and duration) and 3 domains of child development (gross motor, communication, and personal social). Longitudinal data from 303 households (n = 309 children) visited 9 times over 2 years were collected. Children in households experiencing severe food insecurity 3 months prior (timing) had significantly lower gross motor (β −0.14; 95% CI [0.27, −0.0033]; p = .045), communication (β −0.16; 95% CI [−0.30, −0.023]; p = .023), and personal social (β −0.20; 95% CI [−0.33, −0.073]; p = .002) Z‐scores, using lagged longitudinal linear models controlling for current food insecurity; these results were attenuated in full models, which included maternal education, household asset index, and child anthropometry. Children in households that experienced greater aggregate food insecurity over the past 2 years (intensity) had significantly lower gross motor (β −0.047; 95% CI [−0.077, −0.018]; p = .002), communication (β −0.042; 95% CI [−0.076, −0.0073]; p = .018), and personal social (β −0.042; 95% CI [−0.074, −0.010]; p = .010) Z‐scores; these results were also attenuated in full models. Children with more time exposed to food insecurity (duration) had significantly lower gross motor (β −0.050; 95% CI [−0.087, −0.012]; p = .010), communication (β −0.042; 95% CI [−0.086, 0.0013]; p = .057), and personal social (β −0.037; 95% CI [−0.077, 0.0039]; p = .076) Z‐scores; these results were no longer significant in full models. Our findings suggest that acute and chronic food insecurity and child development are related, but that many associations are attenuated with the inclusion of relevant covariates. [ABSTRACT FROM AUTHOR]

Abstract: As the proportion of facility‐based births increases, so does the need to ensure that mothers and their newborns receive quality care. Developing facility‐oriented obstetric and neonatal training programs grounded in principles of teamwork utilizing simulation‐based training for emergency response is an important strategy for improving the quality care. This study uses 3 dimensions of the Kirkpatrick Model to measure the impact of PRONTO International (PRONTO) simulation‐based training as part of the Linda Afya ya Mama na Mtoto (LAMMP, Protect the Health of mother and child) in Kenya. Changes in knowledge of obstetric and neonatal emergency response, self‐efficacy, and teamwork were analyzed using longitudinal, fixed‐effects, linear regression models. Participants from 26 facilities participated in the training between 2013 and 2014. The results demonstrate improvements in knowledge, self‐efficacy, and teamwork self‐assessment. When comparing pre‐Module I scores with post‐training scores, improvements range from 9 to 24 percentage points (p values < .0001 to .026). Compared to baseline, post‐Module I and post‐Module II (3 months later) scores in these domains were similar. The intervention not only improved participant teamwork skills, obstetric and neonatal knowledge, and self‐efficacy but also fostered sustained changes at 3 months. The proportion of facilities achieving self‐defined strategic goals was high: 95.8% of the 192 strategic goals. Participants rated the PRONTO intervention as extremely useful, with an overall score of 1.4 out of 5 (1, extremely useful; 5, not at all useful). Evaluation of how these improvements affect maternal and perinatal clinical outcomes is forthcoming. [ABSTRACT FROM AUTHOR]

Abstract: Calcium (Ca) supplementation to prevent preeclampsia can save maternal and newborn lives, but there are no program models for integration into existing antenatal care platforms. We used a program impact pathway model to guide the design of integrated Ca and iron–folate (IFA) supplementation in Kenya. We provided healthcare providers with job aids (posters and counseling cards), trained them on counseling techniques and supplementation guidelines, and developed behavior change materials for pregnant women (pill‐taking calendars). We allocated health facilities to prescribe either 1.0 or 1.5 g/day Ca, with standard IFA. We collected implementation data from 16 facilities and 990 women. We also explored effects of supplementation on percentage of the population meeting recommended daily allowance. Supplements and job aids were available during 90% of facility spot‐check episodes; calendar availability was lower (78%). Over 98% of clients received Ca and IFA supplements, but only 76% received enough Ca supplements to last between antenatal care visits. Among clients that still had pills by return date, adherence was 77% and 83% for the IFA and Ca regimen, respectively. When 1.5 g/day of Ca supplements were prescribed, over 75% of participants met recommended daily allowance. Only 54% met the recommended daily allowance when 1.0 g was prescribed. This study illustrates a systematic approach for integrating Ca supplementation into primary healthcare and demonstrates that such integration is feasible when contextual bottlenecks are addressed. Policy makers and program planners should pay attention to supply chain, healthcare worker dispensing behavior, and appropriateness of regimen for their settings. [ABSTRACT FROM AUTHOR]

The commonest cause of rickets worldwide is vitamin D deficiency, but studies from sub-Saharan Africa describe an endemic vitamin D-independent form that responds to dietary calcium enrichment. The extent to which calcium-deficiency rickets is the dominant form across sub-Saharan Africa and in other low-latitude areas is unknown. We aimed to characterise the clinical and biochemical features of young children with rickets in a densely populated urban informal settlement in Kenya. Because malnutrition may mask the clinical features of rickets, we also looked for biochemical indices of risk in children with varying degrees of acute malnutrition. Twenty one children with rickets, aged 3 to 24 months, were identified on the basis of clinical and radiologic features, along with 22 community controls, and 41 children with either severe or moderate acute malnutrition. Most children with rickets had wrist widening (100%) and rachitic rosary (90%), as opposed to lower limb features (19%). Developmental delay (52%), acute malnutrition (71%), and stunting (62%) were common. Compared to controls, there were no differences in calcium intake, but most (71%) had serum 25-hydroxyvitamin D levels below 30 nmol/L. These results suggest that rickets in young children in urban Kenya is usually driven by vitamin D deficiency, and vitamin D supplementation is likely to be required for full recovery. Wasting was associated with lower calcium ( p = .001), phosphate ( p < .001), 25-hydroxyvitamin D ( p = .049), and 1,25-dihydroxyvitamin D ( p = 0.022) levels, the clinical significance of which remain unclear. [ABSTRACT FROM AUTHOR]

The prevalence of iron-deficiency anemia (IDA) is high in infants in Sub-Saharan Africa. Exclusive breastfeeding of infants to 6 months of age is recommended by the World Health Organization, but breast milk is low in iron. Some studies suggest exclusive breastfeeding, although beneficial for the infant, may increase risk for IDA in resource-limited settings. The objective of this study was to determine if duration of exclusive breastfeeding is associated with anemia and iron deficiency in rural Kenyan infants. This was a cross-sectional study of 6-10-month-old infants (n = 134) in southern coastal Kenya. Anthropometrics, hemoglobin (Hb), plasma ferritin (PF), soluble transferrin receptor (sTfR), and C-reactive protein were measured. Body iron stores were calculated from the sTfR/PF ratio. Socioeconomic factors, duration of exclusive breastfeeding, nature of complementary diet, and demographic characteristics were determined using a questionnaire. Mean ± SD age of the infants was 7.7 ± 0.8 months. Prevalence of anemia, ID, and IDA were 74.6%, 82.1%, and 64.9%, respectively. Months of exclusive breastfeeding correlated positively with Hb (r = 0.187; p < .05) and negatively with sTfR (r = −0.246; p < .05). sTfR concentrations were lower in infants exclusively breastfed at least 6 months compared with those exclusively breastfed for less than 6 months (7.6 (6.3, 9) vs. 8.9 (6.7, 13.4); p < .05). Controlling for gender, birth weight, and inflammation, months spent exclusively breastfeeding was a significant negative predictor of sTfR and a positive predictor of Hb (p < .05). The IDA prevalence in rural Kenyan infants is high, and greater duration of exclusive breastfeeding predicts better iron status and higher Hb in this age group. [ABSTRACT FROM AUTHOR]

The aim of this study was to explore factors associated with maternal infant and young child feeding motivation in urban and rural Kenya. We conducted 18 focus group discussions with mothers of children 0 to 23 months of age and healthcare workers. The data were transcribed, translated, and explored following the principles of content analysis. We first explored and coded the data inductively and categorized it according to emerging themes representing the most relevant topics for young child feeding. After this, these themes were theorized into an explanatory framework. Finally, the results yielded seven themes integrated into self-determination theory's three basic motivation-building pillars: autonomy, competence, and relatedness. We found that maternal intrahousehold autonomy on child feeding was substantial. However, this autonomy was lost for a period of time while in close contact with the healthcare staff. The authority of the healthcare workers was at its peak when the child was born and faded gradually as the child grew. Building maternal competence is important for child-feeding outcomes, but our data showed that the health education methods used by the healthcare workers were inadequate to improve maternal to improve the motivation. The competence of Kenyan healthcare workers should be improved in the area of complementary feeding counseling, and they should be trained to provide practical and emotional support as a way of increasing maternal motivation on infant and child feeding. [ABSTRACT FROM AUTHOR]

Acute malnutrition affects millions of children each year, yet global coverage of life‐saving treatment through the community‐based management of acute malnutrition (CMAM) is estimated to be below 15%. We investigated the potential role of stigma as a barrier to accessing CMAM. We surveyed caregivers bringing children to rural health facilities in Marsabit County, Kenya, divided into three strata based on the mid‐upper arm circumference of the child: normal status (n = 327), moderate acute malnutrition (MAM, n = 241) and severe acute malnutrition (SAM, n = 143). We used multilevel mixed effects logistic regression to estimate the odds of reporting shame as a barrier to accessing health care. We found that the most common barriers to accessing child health care were those known to be universally problematic: women's time and labour constraints. These constituted the top five most frequently reported barriers regardless of child acute malnutrition status. In contrast, the odds of reporting shame as a barrier were 3.64 (confidence interval: 1.66–8.03, P < 0.05) times higher in caregivers of MAM and SAM children relative to those of normal children. We conclude that stigma is an under‐recognized barrier to accessing CMAM and may constrain programme coverage. In light of the large gap in coverage of CMAM, there is an urgent need to understand the sources of acute malnutrition‐associated stigma and adopt effective means of de‐stigmatization. [ABSTRACT FROM AUTHOR]

As researchers increasingly focus on early infancy as a critical period of development, there is a greater need for methodological tools that can address all aspects of infant growth. Infant skinfold measures, in particular, are measurements in need of reliable reference standards that encompass all ages of infants and provide an accurate assessment of the relative fatness of a population. This report evaluates three published reference standards for infant skinfold measurements: Tanner–Whitehouse, Cambridge Infant Growth Study, and the World Health Organization (WHO) Child Growth Standards. To assess these standards, triceps skinfolds from a population of rural Kenyan infants (n = 250) and triceps skinfolds and subscapular skinfolds from infants in the National Health and Nutrition Examination Survey 1999–2002 (NHANES; n = 1197) were calculated as z‐scores from the lambda‐mu‐sigma curves provided by each reference population. The Tanner–Whitehouse standards represented both the Kenyan and US populations as lean, while the Cambridge standards represented both populations as overfat. The distribution of z‐scores based on the WHO standards fell in the middle, but excluded infants from both populations who were below the age of 3 months. Based on these results, the WHO reference standard is the best skinfold reference standard for infants over the age of 3 months. For populations with infants of all ages, the Tanner–Whitehouse standards are recommended, despite representing both study populations as underfat. Ideally, the WHO will extend their reference standard to include infants between the ages of 0 and 3 months. [ABSTRACT FROM AUTHOR]

Poor breastfeeding practices are widely documented in Kenya, where only a third of children are exclusively breastfed for 6 months and only 2% in urban poor settings. This study aimed to better understand the factors that contribute to poor breastfeeding practices in two urban slums in Nairobi, Kenya. In-depth interviews ( IDIs), focus group discussions ( FGDs) and key informant interviews ( KIIs) were conducted with women of childbearing age, community health workers, village elders and community leaders and other knowledgeable people in the community. A total of 19 IDIs, 10 FGDs and 11 KIIs were conducted, and were recorded and transcribed verbatim. Data were coded in NVIVO and analysed thematically. We found that there was general awareness regarding optimal breastfeeding practices, but the knowledge was not translated into practice, leading to suboptimal breastfeeding practices. A number of social and structural barriers to optimal breastfeeding were identified: (1) poverty, livelihood and living arrangements; (2) early and single motherhood; (3) poor social and professional support; (4) poor knowledge, myths and misconceptions; (5) HIV; and (6) unintended pregnancies. The most salient of the factors emerged as livelihoods, whereby women have to resume work shortly after delivery and work for long hours, leaving them unable to breastfeed optimally. Women in urban poor settings face an extremely complex situation with regard to breastfeeding due to multiple challenges and risk behaviours often dictated to them by their circumstances. Macro-level policies and interventions that consider the ecological setting are needed. [ABSTRACT FROM AUTHOR]

Agricultural strategies such as dairy intensification have potential to improve human nutrition through increased household food security. Increasing dairy productivity could also adversely affect infant and young child feeding (IYCF) practices because of increased maternal stress, demands on maternal time, and beliefs about the timing and appropriate types of complementary foods.Yet, few studies have looked rigorously at how interventions can affect young children (0-60 months).The study explores, within the context of rural dairy farming in Kenya, the relationship between level of household dairy production and selected IYCF practices using a mixed-methods approach. Six focus group discussions with women involved in dairy farming investigated their attitudes towards breastfeeding, introduction of complementary foods and child diets. Ninety-two households involved in three levels of dairy production with at least one child 0-60 months participated in a household survey. Quantitative results indicated that women from higher dairy producing households were more likely to introduce cow's milk to infants before they reached 6 months than women from households not producing any dairy.Themes from the focus group discussions demonstrated that women were familiar with exclusive breastfeeding recommendations, but indicated a preference for mixed feeding of infants. Evidence from this study can inform nutrition education programmes targeted to farmers participating in dairy interventions in rural, low-income settings to minimise potential harm to the nutritional status of children. [ABSTRACT FROM AUTHOR]

Although inherited blood disorders are common among children in many parts of Africa, limited data are available about their prevalence or contribution to childhood anaemia. We conducted a cross-sectional survey of 858 children aged 6-35 months who were randomly selected from 60 villages in western Kenya. Haemoglobin ( Hb), ferritin, malaria, C-reactive protein ( CRP) and retinol binding protein ( RBP) were measured from capillary blood. Using polymerase chain reaction ( PCR), Hb type, −3.7 kb alpha-globin chain deletion, glucose-6-phosphate dehydrogenase ( G6 PD) genotype and haptoglobin ( Hp) genotype were determined. More than 2 out of 3 children had at least one measured blood disorder. Sickle cell trait ( HbAS) and disease ( Hb SS) were found in 17.1% and 1.6% of children, respectively; 38.5% were heterozygotes and 9.6% were homozygotes for α+-thalassaemia. The Hp 2-2 genotype was found in 20.4% of children, whereas 8.2% of males and 6.8% of children overall had G6 PD deficiency. There were no significant differences in the distribution of malaria by the measured blood disorders, except among males with G6 PD deficiency who had a lower prevalence of clinical malaria than males of normal G6 PD genotype ( P = 0.005). After excluding children with malaria parasitaemia, inflammation ( CRP > 5 mg L−1), iron deficiency (ferritin < 12 μg L−1) or vitamin A deficiency ( RBP < 0.7 μg L−1), the prevalence of anaemia among those without α+-thalassaemia (43.0%) remained significantly lower than that among children who were either heterozygotes (53.5%) or homozygotes (67.7%, P = 0.03). Inherited blood disorders are common among pre-school children in western Kenya and are important contributors to anaemia. [ABSTRACT FROM AUTHOR]

To evaluate the sustainability of market-based community distribution of micronutrient powders ( Sprinkles®, Hexagon Nutrition, Mumbai, India.) among pre-school children in Kenya, we conducted in August 2010 a follow-up survey, 18 months after study-related marketing and household monitoring ended. We surveyed 849 children aged 6-35 months randomly selected from 60 study villages. Nutritional biomarkers were measured by fingerstick; demographic characteristics, Sprinkles purchases and use were assessed through household questionnaires. We compared Sprinkles use, marketing efforts and biomarker levels with the data from surveys conducted in March 2007, March 2008 and March 2009. We used logistic regression to evaluate associations between marketing activities and Sprinkles use in the 2010 survey. At the 2010 follow-up, 21.9% of children used Sprinkles in the previous 7 days, compared with 64.9% in 2008 ( P < 0.001). Average intake was 3.2 sachets week−1 in 2008, 1.6 sachets week−1 in 2009 and 1.1 sachets week−1 in 2010 ( P < 0.001). Factors associated with recent Sprinkles use in 2010 included young age [6-23 months vs. 24-35 months, adjusted odds ratio (a OR) = 1.5, P = 0.02], lowest 2 quintiles of socio-economic status (a OR = 1.7, P = 0.004), household attendance at trainings or launches (a OR = 2.8, P < 0.001) and ever receiving promotional items including free Sprinkles, calendars, cups and t-shirts (a OR = 1.7, P = 0.04). In 2010, there was increased prevalence of anaemia and malaria ( P < 0.001), but not iron deficiency ( P = 0.44), compared with that in 2008. Sprinkles use in 2010 was associated with decreased iron deficiency ( P = 0.03). Sprinkles coverage reduced after stopping household monitoring and reducing marketing activities. Continued promotion and monitoring of Sprinkles usage may be important components to sustain the programme. [ABSTRACT FROM AUTHOR]

High levels of food insecurity and human immunodeficiency virus (HIV) infection place most breastfeeding mothers in Kenya at high risk of malnutrition. We examined the role of selected socio-economic, demographic and health factors as determinants of nutritional status among HIV-infected and HIV-uninfected mothers in rural Kenya and further examined the interrelationship between maternal nutritional and child nutritional status within this population. A cross-sectional design was used to collect data from non-pregnant mothers with children ages 4-24 months in Kisumu District, Kenya. Over 80% of the mothers were breastfeeding at the time of the study. Mean maternal body mass index (BMI) (21.60 ± 3.15) and percent body fat (22.29 ± 4.86) values were lower than among lactating mothers in other Sub-Sahara African countries. Maternal HIV status was not significantly associated with any of the maternal nutritional indicators assessed in the study. Breastfeeding, recent severe illness and having multiple children below 2 years of age were negatively associated with maternal nutritional status, while higher maternal age, socio-economic status and household food security were each positively associated with maternal nutritional status. Significant positive association was reported between maternal weight, height, BMI, mid-upper arm circumference (MUAC), body fat and fat-free mass estimates, and children's height-for-age, weight-for-age, weight-for-height and MUAC-for-age z-score. This analysis identifies determinants of maternal nutritional status in rural Kenya and highlights the importance of interventions that address malnutrition in both HIV-infected and HIV-uninfected mothers in rural Kenya. Significant association between maternal and child nutritional status stresses the importance of addressing maternal and young child nutritional status as interrelated factors. [ABSTRACT FROM AUTHOR]

This study aimed to document whether food insecurity was associated with beliefs and attitudes towards exclusive breastfeeding (EBF) among urban Kenyan women. We conducted structured interviews with 75 human immunodeficiency virus (HIV)-affected and 75 HIV-status unknown, low-income women who were either pregnant or with a child ≤24 months and residing in Nakuru, Kenya to generate categorical and open-ended responses on knowledge, attitudes and beliefs towards EBF and food insecurity. We facilitated six focus group discussions (FGD) with HIV-affected and HIV-status unknown mothers ( n = 50 women) to assess barriers and facilitators to EBF. Of 148 women with complete interview data, 77% were moderately or severely food insecure (FIS). Women in FIS households had significantly greater odds of believing that breast milk would be insufficient for 6 months [odds ratio (OR), 2.6; 95% confidence interval (95% CI), 1.0, 6.8], that women who EBF for 6 months would experience health or social problems (OR, 2.7; 95% CI, 1.0, 7.3), that women need adequate food to support EBF for 6 months (OR, 2.6; 95% CI, 1.0, 6.7) and that they themselves would be unable to follow a counsellor's advice to EBF for 6 months (OR, 3.2; 95% CI, 1.3, 8.3). Qualitative analysis of interview and FGD transcripts indicated that the maternal experience of hunger contributes to perceived milk insufficiency, anxiety about infant hunger and a perception that access to adequate food is necessary for successful breastfeeding. The lived experience of food insecurity among a sample of low-income, commonly FIS, urban Kenyan women reduces their capacity to implement at least one key recommended infant feeding practices, that of EBF for 6 months. [ABSTRACT FROM AUTHOR]

Reestablishing exclusive breastfeeding is the cornerstone of the 2013 World Health Organization (WHO) treatment guidelines for acute malnutrition in infants less than 6 months. However, no studies have investigated guideline implementation and subsequent outcomes in a public hospital setting in Africa. To facilitate implementation of the WHO 2013 guidelines in Kilifi County Hospital, Kenya, we developed standard operating procedure, recruited, and trained three breastfeeding peer supporters (BFPS). Between September 2016 and January 2018, the BFPS provided individual breastfeeding support to mothers of infants aged 4 weeks to 4 months admitted to Kilifi County Hospital with an illness and acute malnutrition (mid‐upper‐arm circumference < 11.0 cm OR weight‐for‐age z score < −2 OR weight‐for‐length z score < ‐2). Infants were followed daily while in hospital then every 2 weeks for 6 weeks after discharge with data collected on breastfeeding, infant growth, morbidity, and mortality. Of 106 infants with acute malnutrition at admission, 51 met the inclusion criteria for the study. Most enrolled mothers had multiple breastfeeding challenges, which were predominantly technique based. Exclusive breastfeeding was 55% at admission and 81% at discharge; at discharge 67% of infants had attained a weight velocity of >5 g/kg/day for three consecutive days on breastmilk alone. Gains in weight‐for‐length z score and weight‐for‐age z score were generally not sustained beyond 2 weeks after discharge. BFPS operated effectively in an inpatient setting, applying the 2013 updated WHO guidelines and increasing rates of exclusive breastfeeding at discharge. However, lack of continued increase in anthropometric Z scores after discharge suggests the need for more sustained interventions. [ABSTRACT FROM AUTHOR]

Food insecurity and poor infant and young child feeding (IYCF) practices contribute to undernutrition. The Kanyakla Nutrition Program was developed in rural Kenya to provide knowledge alongside social support for recommended IYCF practices. Utilizing a social network approach, the Kanyakla Nutrition Program trained community health workers (CHWs) to engage mothers, fathers, and grandparents in nutrition education and discussions about strategies to provide instrumental, emotional, and information support within their community. The 12‐week programme included six sessions and was implemented on Mfangano Island, Kenya, in 2014–2015. We analysed intervention effects on (a) nutrition knowledge among community members or CHWs and (2) IYCF practices among children 1–3 years. Nutrition knowledge was assessed using a postintervention comparison among intervention (community, n = 43; CHW, n = 22) and comparison groups (community, n = 149; CHW, n = 64). We used a quasi‐experimental design and difference‐in‐difference to assess IYCF indicators using dietary recall data from an ongoing cohort study among intervention participants (n = 48) with individuals living on Mfangano Island where the intervention was not implemented (n = 178) before the intervention, within 1 month postintervention, and 6 months postintervention. Findings showed no effect of the intervention on IYCF indicators (e.g., dietary diversity and meal frequency), and less than 15% of children met minimum acceptable diet criteria at any time point. However, knowledge and confidence among community members and CHWs were significantly higher 2 years postintervention. Thus, a social network approach had an enduring effect on nutrition knowledge, but no effects on improved IYCF practices. [ABSTRACT FROM AUTHOR]

The Baby‐Friendly Community Initiative (BFCI) is an extension of the 10th step of the Ten Steps of Successful Breastfeeding and the Baby‐Friendly Hospital Initiative (BFHI) and provides continued breastfeeding support to communities upon facility discharge after birth. BFCI creates a comprehensive support system at the community level through the establishment of mother‐to‐mother and community support groups to improve breastfeeding. The Government of Kenya has prioritized community‐based programming in the country, including the development of the first national BFCI guidelines, which inform national and subnational level implementation. This paper describes the process of BFCI implementation within the Kenyan health system, as well as successes, challenges, and opportunities for integration of BFCI into health and other sectors. In Maternal and Child Survival Program (MCSP) and UNICEF areas, 685 community leaders were oriented to BFCI, 475 health providers trained, 249 support groups established, and 3,065 children 0–12 months of age reached (MCSP only). Though difficult to attribute to our programme, improvements in infant and young child feeding practices were observed from routine health data following the programme, with dramatic declines in prelacteal feeding (19% to 11%) in Kisumu County and (37.6% to 5.1%) in Migori County from 2016 to 2017. Improvements in initiation and exclusive breastfeeding in Migori were also noted—from 85.9% to 89.3% and 75.2% to 92.3%, respectively. Large gains in consumption of iron‐rich complementary foods were also seen (69.6% to 90.0% in Migori, 78% to 90.9% in Kisumu) as well as introduction of complementary foods (42.0–83.3% in Migori). Coverage for BFCI activities varied across counties, from 20% to 60% throughout programme implementation and were largely sustained 3 months postimplementation in Migori, whereas coverage declined in Kisumu. BFCI is a promising platform to integrate into other sectors, such as early child development, agriculture, and water, sanitation, and hygiene. [ABSTRACT FROM AUTHOR]

Smallholder farmers dependent on rain‐fed agriculture experience seasonal variations in food and nutrient availability occasioned by seasonality of production patterns. This results in periods of nutrient abundance in the plenty seasons followed closely by periods of nutrient inadequacies and malnutrition. This pattern contributes to a cycle of deteriorating health and nutrition status and deprives children of their ability to realize full developmental potential. This study investigates the role of caregiver's nutritional knowledge and attitudes in mediating effects of seasonality on children's diets. Repeated cross‐sectional surveys were conducted on 151 randomly selected households in the plenty and lean seasons to collect dietary data using two non‐consecutive quantitative 24‐hr recalls and caregiver's nutritional knowledge and attitudes assessed using interviewer administered questionnaire. Sixty‐five percent of the caregivers had attained a primary level education or less. There was a positive modest correlation between caregivers' nutritional knowledge and their attitudes (r = 0.3, P < 0.000, α = 0.01). Children's mean adequacy ratio was significantly higher in the plenty season than in the lean season (0.84 vs. 0.80, P < 0.000). A two‐block hierarchical regression to predict the seasonal changes in dietary quality of children using caregiver's nutritional knowledge and attitude scores while controlling for the effect of sociodemographics and mean adequacy ratio at first season (plenty) found that caregiver's nutritional knowledge (ß = −0.007, SE = 0.003, P = 0.027, 95% CI [−0.013, −0.001] ŋ2 = 0.034) but not attitudes had significant contribution to the prediction. Maternal nutritional knowledge mediates seasonal variation in child nutrient intakes. [ABSTRACT FROM AUTHOR]

Antenatal calcium and iron-folic acid (IFA) supplementation can reduce maternal mortality and morbidity. Yet, even when pregnant women have a stable supply of supplements, forgetting is often a barrier to adherence. We assessed the acceptability of adherence partners to support calcium and IFA supplementation among pregnant women in Kenya and Ethiopia. Adherence partners are a behaviour change strategy to improve adherence, where pregnant women are counselled to select a partner (e.g. spouse, relative) to remind them to take their supplements. We conducted trials of improved practices, a formative research method that follows participants over time as they try a new behaviour. We provided pregnant women in Ethiopia ( n = 50) and Kenya ( n = 35) with calcium and IFA supplements and counselling, and suggested selecting an adherence partner. For each participant, we conducted semi-structured interviews about acceptability and adherence during four interviews over six weeks. We analysed interview transcripts thematically and tallied numerical data. In Kenya, 28 of 35 women agreed to try an adherence partner; almost all selected their husbands. In Ethiopia, 42 of 50 women agreed to try an adherence partner; half asked their husbands, others asked children or relatives. Most women who did not select adherence partners reported not needing help or not having anyone to ask. Participants reported adherence partners reminded and encouraged them, brought supplements, provided food and helped address side-effects. Almost all women with adherence partners would recommend this strategy to others. Adherence partners are an acceptable, low-cost strategy with the potential to support antenatal micronutrient supplementation adherence. [ABSTRACT FROM AUTHOR]