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Background: Urban sprawl in many developing nations has led to an increase in the rates of childhood obesity and overweight. An increase in sedentary lifestyle and consumption of high calorie foods and drinks are among the major reasons contributing to this change. During the Covid 19 pandemic the rate of obesity among children increased compared to pre-pandemic period. Objective: This study aimed to assess the prevalence and risk factors of overweight and obesity among children seen as outpatient. Study Design and Setting: The study was a cross-sectional study conducted at the paediatric emergency unit and accident and emergency department in Kenyatta National Hospital (KNH). Participants: The study population was outpatient children aged two to twelve years seen at the paediatric emergency unit and accident and emergency department in Kenyatta National Hospital over a period of 5 months. Materials and methods: Weight and height were measured, and body mass index calculated. A questionnaire was administered, and nutritional status assessment done using the CDC gender specific BMI charts. Results: The prevalence of obesity was 14% and overweight was at 8%. School going age, household monthly income and transport to school had significant association with obesity and overweight. Conclusion: The prevalence of obesity and overweight was high among children seen at the emergency departments in Kenyatta National Hospital. [ABSTRACT FROM AUTHOR]

Background: The emergence of COVID-19 precipitated containment policies (e.g., lockdowns, school closures, etc.). These policies disrupted healthcare, potentially eroding gains for Sustainable Development Goals including for neonatal mortality. Our analysis aimed to evaluate indirect effects of COVID-19 containment policies on neonatal admissions and mortality in 67 neonatal units across Kenya, Malawi, Nigeria, and Tanzania between January 2019 and December 2021., Methods: The Oxford Stringency Index was applied to quantify COVID-19 policy stringency over time for Kenya, Malawi, Nigeria, and Tanzania. Stringency increased markedly between March and April 2020 for these four countries (although less so in Tanzania), therefore defining the point of interruption. We used March as the primary interruption month, with April for sensitivity analysis. Additional sensitivity analysis excluded data for March and April 2020, modelled the index as a continuous exposure, and examined models for each country. To evaluate changes in neonatal admissions and mortality based on this interruption period, a mixed effects segmented regression was applied. The unit of analysis was the neonatal unit (n = 67), with a total of 266,741 neonatal admissions (January 2019 to December 2021)., Results: Admission to neonatal units decreased by 15% overall from February to March 2020, with half of the 67 neonatal units showing a decline in admissions. Of the 34 neonatal units with a decline in admissions, 19 (28%) had a significant decrease of ≥ 20%. The month-to-month decrease in admissions was approximately 2% on average from March 2020 to December 2021. Despite the decline in admissions, we found no significant changes in overall inpatient neonatal mortality. The three sensitivity analyses provided consistent findings., Conclusion: COVID-19 containment measures had an impact on neonatal admissions, but no significant change in overall inpatient neonatal mortality was detected. Additional qualitative research in these facilities has explored possible reasons. Strengthening healthcare systems to endure unexpected events, such as pandemics, is critical in continuing progress towards achieving Sustainable Development Goals, including reducing neonatal deaths to less than 12 per 1000 live births by 2030., (© 2024. The Author(s).)

Preterm birth (< 37 weeks gestation) complications are the leading cause of neonatal mortality. Early-warning scores (EWS) are charts where vital signs (e.g., temperature, heart rate, respiratory rate) are recorded, triggering action. To evaluate whether a neonatal EWS improves clinical outcomes in low-middle income countries, a randomised trial is needed. Determining whether the use of a neonatal EWS is feasible and acceptable in newborn units, is a prerequisite to conducting a trial. We implemented a neonatal EWS in three newborn units in Kenya. Staff were asked to record infants' vital signs on the EWS during the study, triggering additional interventions as per existing local guidelines. No other aspects of care were altered. Feasibility criteria were pre-specified. We also interviewed health professionals (n = 28) and parents/family members (n = 42) to hear their opinions of the EWS. Data were collected on 465 preterm and/or low birthweight (< 2.5 kg) infants. In addition to qualitative study participants, 45 health professionals in participating hospitals also completed an online survey to share their views on the EWS. 94% of infants had the EWS completed at least once during their newborn unit admission. EWS completion was highest on the day of admission (93%). Completion rates were similar across shifts. 15% of vital signs triggered escalation to a more senior member of staff. Health professionals reported liking the EWS, though recognised the biggest barrier to implementation was poor staffing. Newborn unit infant to staff ratios varied between 10 and 53 staff per 1 infant, depending upon time of shift and staff type. A randomised trial of neonatal EWS in Kenya is possible and acceptable, though adaptations are required to the form before implementation., (© 2024. The Author(s).)

Background: Thirty million small and sick newborns worldwide require inpatient care each year. Many receive antibiotics for clinically diagnosed infections without blood cultures, the current 'gold standard' for neonatal infection detection. Low neonatal blood culture use hampers appropriate antibiotic use, fuelling antimicrobial resistance (AMR) which threatens newborn survival. This study analysed the gap between blood culture use and antibiotic prescribing in hospitals implementing with Newborn Essential Solutions and Technologies (NEST360) in Kenya, Malawi, Nigeria, and Tanzania., Methods: Inpatient data from every newborn admission record (July 2019-August 2022) were included to describe hospital-level blood culture use and antibiotic prescription. Health Facility Assessment data informed performance categorisation of hospitals into four tiers: (Tier 1) no laboratory, (Tier 2) laboratory but no microbiology, (Tier 3) neonatal blood culture use < 50% of newborns receiving antibiotics, and (Tier 4) neonatal blood culture use > 50%., Results: A total of 144,146 newborn records from 61 hospitals were analysed. Mean hospital antibiotic prescription was 70% (range = 25-100%), with 6% mean blood culture use (range = 0-56%). Of the 10,575 blood cultures performed, only 24% (95%CI 23-25) had results, with 10% (10-11) positivity. Overall, 40% (24/61) of hospitals performed no blood cultures for newborns. No hospitals were categorised as Tier 1 because all had laboratories. Of Tier 2 hospitals, 87% (20/23) were District hospitals. Most hospitals could do blood cultures (38/61), yet the majority were categorised as Tier 3 (36/61). Only two hospitals performed > 50% blood cultures for newborns on antibiotics (Tier 4)., Conclusions: The two Tier 4 hospitals, with higher use of blood cultures for newborns, underline potential for higher blood culture coverage in other similar hospitals. Understanding why these hospitals are positive outliers requires more research into local barriers and enablers to performing blood cultures. Tier 3 facilities are missing opportunities for infection detection, and quality improvement strategies in neonatal units could increase coverage rapidly. Tier 2 facilities could close coverage gaps, but further laboratory strengthening is required. Closing this culture gap is doable and a priority for advancing locally-driven antibiotic stewardship programmes, preventing AMR, and reducing infection-related newborn deaths., (© 2023. The Author(s).)

Background: Data from High Income Countries have now linked low nurse staff to patient ratios to poor quality patient care. Adequately staffing hospitals is however still a challenge in resource-constrained Low-middle income countries (LMICs) and poor staff-to-patient ratios are largely taken as a norm. This in part relates to limited evidence on the relationship between staffing and quality of patient care in these settings and also an absence of research on benefits that might occur from improving hospital staff numbers in LMICs. This study will determine the effect on the quality of patient care of prospectively adding extra nursing staff to newborn units in a resource constrained LMIC setting and describe the relationship between staffing and quality of care., Methods: This prospective workforce intervention study will involve a multi-method approach. We will conduct a before and after study in newborn units of 4 intervention hospitals and a single time-point comparison in 4 non-intervention hospitals to determine if there is a change in the level of missed nursing care, a process measure of the quality of patient care. We will also determine the effect of our intervention on routinely collected quality indicators using interrupted time series analysis. Using three nurse staffing metrics (Total nursing hours, nursing hours per patient day and nursing hours per patient per shift), we will describe the relationship between staffing and the quality of patient care., Discussion: There is an urgent need for the implementation of staffing policies in resource constrained LMICs that are guided by relevant contextual data. To the best of our knowledge, this is the first study to evaluate the prospective addition of nursing staff in resource-constrained care settings. Our findings are likely to provide the much-needed evidence for better staffing in these settings., Trial Registration: This study was retrospectively registered in the Pan African Clinical Trial Registry ( https://pactr.samrc.ac.za/Default.aspx?Logout=True ) database on the 10th of June 2022 with a unique identification number-PACTR202206477083141., (© 2022. The Author(s).)

Objective: Multidrug-resistant organisms (MDRO), especially carbapenem-resistant organisms (CRO), represent a threat for newborns. This study investigates the colonization prevalence of these pathogens in a newborn unit at a Kenyan tertiary hospital in an integrated approach combining routine microbiology, whole genome sequencing (WGS) and hospital surveillance data., Methods: The study was performed in the Kenyatta National Hospital (KNH) in 2019 over a four-month period and included 300 mother-baby pairs. A total of 1,097 swabs from newborns (weekly), mothers (once) and the hospital environment were taken. Routine clinical microbiology methods were applied for surveillance. Of the 288 detected MDRO, 160 isolates were analyzed for antimicrobial resistance genes and phylogenetic relatedness using whole genome sequencing (WGS) and bioinformatic analysis., Results: In maternal vaginal swabs, MDRO detection rate was 15% (n=45/300), including 2% CRO (n=7/300). At admission, MDRO detection rate for neonates was 16% (n=48/300), including 3% CRO (n=8/300) with a threefold increase for MDRO (44%, n=97/218) and a fivefold increase for CRO (14%, n=29/218) until discharge. Among CRO, K. pneumoniae harboring bla NDM-1 (n=20) or bla NDM-5 (n=16) were most frequent. WGS analysis revealed 20 phylogenetically related transmission clusters (including five CRO clusters). In environmental samples, the MDRO detection rate was 11% (n=18/164), including 2% CRO (n=3/164)., Conclusion: Our study provides a snapshot of MDRO and CRO in a Kenyan NBU. Rather than a large outbreak scenario, data indicate several independent transmission events. The CRO rate among newborns attributed to the spread of NDM-type carbapenemases is worrisome., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Villinger, Schultze, Musyoki, Inwani, Aluvaala, Okutoyi, Ziegler, Wieters, Stephan, Museve, Kempf and Masika.)

Background: Two neonatal mortality prediction models, the Neonatal Essential Treatment Score (NETS) which uses treatments prescribed at admission and the Score for Essential Neonatal Symptoms and Signs (SENSS) which uses basic clinical signs, were derived in high-mortality, low-resource settings to utilise data more likely to be available in these settings. In this study, we evaluate the predictive accuracy of two neonatal prediction models for all-cause in-hospital mortality., Methods: We used retrospectively collected routine clinical data recorded by duty clinicians at admission from 16 Kenyan hospitals used to externally validate and update the SENSS and NETS models that were initially developed from the data from the largest Kenyan maternity hospital to predict in-hospital mortality. Model performance was evaluated by assessing discrimination and calibration. Discrimination, the ability of the model to differentiate between those with and without the outcome, was measured using the c-statistic. Calibration, the agreement between predictions from the model and what was observed, was measured using the calibration intercept and slope (with values of 0 and 1 denoting perfect calibration)., Results: At initial external validation, the estimated mortality risks from the original SENSS and NETS models were markedly overestimated with calibration intercepts of - 0.703 (95% CI - 0.738 to - 0.669) and - 1.109 (95% CI - 1.148 to - 1.069) and too extreme with calibration slopes of 0.565 (95% CI 0.552 to 0.577) and 0.466 (95% CI 0.451 to 0.480), respectively. After model updating, the calibration of the model improved. The updated SENSS and NETS models had calibration intercepts of 0.311 (95% CI 0.282 to 0.350) and 0.032 (95% CI - 0.002 to 0.066) and calibration slopes of 1.029 (95% CI 1.006 to 1.051) and 0.799 (95% CI 0.774 to 0.823), respectively, while showing good discrimination with c-statistics of 0.834 (95% CI 0.829 to 0.839) and 0.775 (95% CI 0.768 to 0.782), respectively. The overall calibration performance of the updated SENSS and NETS models was better than any existing neonatal in-hospital mortality prediction models externally validated for settings comparable to Kenya., Conclusion: Few prediction models undergo rigorous external validation. We show how external validation using data from multiple locations enables model updating and improving their performance and potential value. The improved models indicate it is possible to predict in-hospital mortality using either treatments or signs and symptoms derived from routine neonatal data from low-resource hospital settings also making possible their use for case-mix adjustment when contrasting similar hospital settings., (© 2022. The Author(s).)

Background: Partners from an NGO, academia, industry and government applied a tool originating in the private sector - Quantitative Decision Making (QDM) - to rigorously assess whether to invest in testing a global health intervention. The proposed NEWBORN study was designed to assess whether topical emollient therapy with sunflower seed oil in infants with very low birthweight <1500 g in Kenya would result in a significant reduction in neonatal mortality compared to standard of care., Methods: The QDM process consisted of prior elicitation, modelling of prior distributions, and simulations to assess Probability of Success (PoS) via assurance calculations. Expert opinion was elicited on the probability that emollient therapy with sunflower seed oil will have any measurable benefit on neonatal mortality based on available evidence. The distribution of effect sizes was modelled and trial data simulated using Statistical Analysis System to obtain the overall assurance which represents the PoS for the planned study. A decision-making framework was then applied to characterise the ability of the study to meet pre-selected decision-making endpoints., Results: There was a 47% chance of a positive outcome (defined as a significant relative reduction in mortality of ≥15%), a 45% chance of a negative outcome (defined as a significant relative reduction in mortality <10%), and an 8% chance of ending in the consider zone (ie, a mortality reduction of 10 to <15%) for infants <1500 g., Conclusions: QDM is a novel tool from industry which has utility for prioritisation of investments in global health, complementing existing tools [eg, Child Health and Nutrition Research Initiative]. Results from application of QDM to the NEWBORN study suggests that it has a high probability of producing clear results. Findings encourage future formation of public-private partnerships for health., Competing Interests: Competing interests: AS, RAG, and LKK are current or former employees and shareholders of GlaxoSmithKline. SW, RM, AC, and LK are current or former employees of Save the Children. The authors have completed the ICMJE Declaration of Interest form (available upon request from the corresponding author), and declare no further conflicts of interest., (Copyright © 2022 by the Journal of Global Health. All rights reserved.)

Background: Medication errors are likely common in low- and middle-income countries (LMICs). In neonatal hospital care where the population with severe illness has a high mortality rate, around 14.9% of drug prescriptions have errors in LMICs settings. However, there is scant research on interventions to improve medication safety to mitigate such errors. Our objective is to improve routine neonatal care particularly focusing on effective prescribing practices with the aim of achieving reduced gentamicin medication errors., Methods: We propose to conduct an audit and feedback (A&F) study over 12 months in 20 hospitals with 12 months of baseline data. The medical and nursing leaders on their newborn units had been organised into a network that facilitates evaluating intervention approaches for improving quality of neonatal care in these hospitals and are receiving basic feedback generated from the baseline data. In this study, the network will (1) be expanded to include all hospital pharmacists, (2) include a pharmacist-only professional WhatsApp discussion group for discussing prescription practices, and (3) support all hospitals to facilitate pharmacist-led continuous medical education seminars on prescription practices at hospital level, i.e. default intervention package. A subset of these hospitals (n = 10) will additionally (1) have an additional hospital-specific WhatsApp group for the pharmacists to discuss local performance with their local clinical team, (2) receive detailed A&F prescription error reports delivered through mobile-based dashboard, and (3) receive a PDF infographic summarising prescribing performance circulated to the clinicians through the hospital-specific WhatsApp group, i.e. an extended package. Using interrupted time series analysis modelling changes in prescribing errors over time, coupled with process fidelity evaluation, and WhatsApp sentiment analysis, we will evaluate the success with which the A&F interventions are delivered, received, and acted upon to reduce prescribing error while exploring the extended package's success/failure relative to the default intervention package., Discussion: If effective, these theory-informed A&F strategies that carefully consider the challenges of LMICs settings will support the improvement of medication prescribing practices with the insights gained adapted for other clinical behavioural targets of a similar nature., Trial Registration: PACTR, PACTR202203869312307 . Registered 17th March 2022., (© 2022. The Author(s).)

Objectives: To characterise adoption and explore specific clinical and patient factors that might influence pulse oximetry and oxygen use in low-income and middle-income countries (LMICs) over time; to highlight useful considerations for entities working on programmes to improve access to pulse oximetry and oxygen., Design: A multihospital retrospective cohort study., Settings: All admissions (n=132 737) to paediatric wards of 18 purposely selected public hospitals in Kenya that joined a Clinical Information Network (CIN) between March 2014 and December 2020., Outcomes: Pulse oximetry use and oxygen prescription on admission; we performed growth-curve modelling to investigate the association of patient factors with study outcomes over time while adjusting for hospital factors., Results: Overall, pulse oximetry was used in 48.8% (64 722/132 737) of all admission cases. Use rose on average with each month of participation in the CIN (OR: 1.11, 95% CI 1.05 to 1.18) but patterns of adoption were highly variable across hospitals suggesting important factors at hospital level influence use of pulse oximetry. Of those with pulse oximetry measurement, 7% (4510/64 722) had hypoxaemia (SpO 2 <90%). Across the same period, 8.6% (11 428/132 737) had oxygen prescribed but in 87%, pulse oximetry was either not done or the hypoxaemia threshold (SpO 2 <90%) was not met. Lower chest-wall indrawing and other respiratory symptoms were associated with pulse oximetry use at admission and were also associated with oxygen prescription in the absence of pulse oximetry or hypoxaemia., Conclusion: The adoption of pulse oximetry recommended in international guidelines for assessing children with severe illness has been slow and erratic, reflecting system and organisational weaknesses. Most oxygen orders at admission seem driven by clinical and situational factors other than the presence of hypoxaemia. Programmes aiming to implement pulse oximetry and oxygen systems will likely need a long-term vision to promote adoption, guideline development and adherence and continuously examine impact., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Objectives: To examine the prevalence of dehydration without diarrhoea among admitted children aged 1-59 months and to describe fluid management practices in such cases., Design: A multisite observational study that used routine in-patient data collected prospectively between October 2013 and December 2018., Settings: Study conducted in 13 county referral hospitals in Kenya., Participants: Children aged 1-59 months with admission or discharge diagnosis of dehydration but had no diarrhoea as a symptom or diagnosis. Children aged <28 days and those with severe acute malnutrition were excluded., Results: The prevalence of dehydration in children without diarrhoea was 3.0% (2019/68 204) and comprised 15.9% (2019/12 702) of all dehydration cases. Only 55.8% (1127/2019) of affected children received either oral or intravenous fluid therapy. Where fluid treatment was given, the volumes, type of fluid, duration of fluid therapy and route of administration were similar to those used in the treatment of dehydration secondary to diarrhoea. Pneumonia (1021/2019, 50.6%) and malaria (715/2019, 35.4%) were the two most common comorbid diagnoses. Overall case fatality in the study population was 12.9% (260/2019)., Conclusion: Sixteen per cent of children hospitalised with dehydration do not have diarrhoea but other common illnesses. Two-fifths do not receive fluid therapy; a regimen similar to that used in diarrhoeal cases is used in cases where fluid is administered. Efforts to promote compliance with guidance in routine clinical settings should recognise special circumstances where guidelines do not apply, and further studies on appropriate management for dehydration in the absence of diarrhoea are required., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Most of the deaths among neonates in low-income and middle-income countries (LMICs) can be prevented through universal access to basic high-quality health services including essential facility-based inpatient care. However, poor routine data undermines data-informed efforts to monitor and promote improvements in the quality of newborn care across hospitals., Methods: Continuously collected routine patients' data from structured paper record forms for all admissions to newborn units (NBUs) from 16 purposively selected Kenyan public hospitals that are part of a clinical information network were analysed together with data from all paediatric admissions ages 0-13 years from 14 of these hospitals. Data are used to show the proportion of all admissions and deaths in the neonatal age group and examine morbidity and mortality patterns, stratified by birth weight, and their variation across hospitals., Findings: During the 354 hospital months study period, 90 222 patients were admitted to the 14 hospitals contributing NBU and general paediatric ward data. 46% of all the admissions were neonates (aged 0-28 days), but they accounted for 66% of the deaths in the age group 0-13 years. 41 657 inborn neonates were admitted in the NBUs across the 16 hospitals during the study period. 4266/41 657 died giving a crude mortality rate of 10.2% (95% CI 9.97% to 10.55%), with 60% of these deaths occurring on the first-day of admission. Intrapartum-related complications was the single most common diagnosis among the neonates with birth weight of 2000 g or more who died. A threefold variation in mortality across hospitals was observed for birth weight categories 1000-1499 g and 1500-1999 g., Interpretation: The high proportion of neonatal deaths in hospitals may reflect changing patterns of childhood mortality. Majority of newborns died of preventable causes (>95%). Despite availability of high-impact low-cost interventions, hospitals have high and very variable mortality proportions after stratification by birth weight., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

We have worked to develop a Clinical Information Network (CIN) in Kenya as an early form of learning health systems (LHS) focused on paediatric and neonatal care that now spans 22 hospitals. CIN's aim was to examine important outcomes of hospitalisation at scale, identify and ultimately solve practical problems of service delivery, drive improvements in quality and test interventions. By including multiple routine settings in research, we aimed to promote generalisability of findings and demonstrate potential efficiencies derived from LHS. We illustrate the nature and range of research CIN has supported over the past 7 years as a form of LHS. Clinically, this has largely focused on common, serious paediatric illnesses such as pneumonia, malaria and diarrhoea with dehydration with recent extensions to neonatal illnesses. CIN also enables examination of the quality of care, for example that provided to children with severe malnutrition and the challenges encountered in routine settings in adopting simple technologies (pulse oximetry) and more advanced diagnostics (eg, Xpert MTB/RIF). Although regular feedback to hospitals has been associated with some improvements in quality data continue to highlight system challenges that undermine provision of basic, quality care (eg, poor access to blood glucose testing and routine microbiology). These challenges include those associated with increased mortality risk (eg, delays in blood transfusion). Using the same data the CIN platform has enabled conduct of randomised trials and supports malaria vaccine and most recently COVID-19 surveillance. Employing LHS principles has meant engaging front-line workers, clinical managers and national stakeholders throughout. Our experience suggests LHS can be developed in low and middle-income countries that efficiently enable contextually appropriate research and contribute to strengthening of health services and research systems., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background Increasing numbers of neonates are undergoing painful procedures in low-income and middle-income countries, with adequate analgesia seldom used. In collaboration with a multi-disciplinary team in Kenya, we aimed to establish the first evidence-based guidelines for the management of routine procedure-related neonatal pain that consider low-resource hospital settings., Methods: We did a systematic review by searching MEDLINE, Embase, CINAHL, and CENTRAL databases for studies published from Jan 1, 1953, to March 31, 2019. We included data from randomised controlled trials using heart rate, oxygen saturation (SpO 2 ), premature infant pain profile (PIPP) score, neonatal infant pain scale (NIPS) score, neonatal facial coding system score, and douleur aiguë du nouveau-né scale score as pain outcome measures. We excluded studies in which neonates were undergoing circumcision or were intubated, studies from which data were unextractable, or when pain was scored by non-trained individuals. We did a narrative synthesis of all studies, and meta-analysis when data were available from multiple studies comparing the same analgesics and controls and using the same outcome measures. 17 Kenyan health-care professionals formed our clinical guideline development panel, and we used the Grading of Recommendations, Assessment, Development and Evaluation framework and the panel's knowledge of the local health-care context to guide the guideline development process. This study is registered with PROSPERO, CRD42019126620., Findings: Of 2782 studies assessed for eligibility, data from 149 (5%) were analysed, with 80 (3%) of these further contributing to our meta-analysis. We found a high level of certainty for the superiority of breastfeeding over placebo or no intervention (standardised mean differences [SMDs] were -1·40 [95% CI -1·96 to -0·84] in PIPP score and -2·20 [-2·91 to -1·48] in NIPS score), and the superiority of oral sugar solutions over placebo or no intervention (SMDs were -0·38 [-0·61 to -0·16] in heart rate and 0·23 [0·04 to 0·42] in SpO 2 ). We found a moderate level of certainty for the superiority for expressed breastmilk over placebo or no intervention (SMDs were -0·46 [95% CI -0·87 to -0·05] in heart rate and 0·48 [0·20 to 0·75] in SpO 2 ). Therefore, the panel recommended that breastfeeding should be given as first-line analgesic treatment, initiated at least 2 min pre-procedure. Given contextual factors, for neonates who are unable to breastfeed, 1-2 mL of expressed breastmilk should be given as first-line analgesic, or 1-2 mL of oral sugar (≥10% concentration) as second-line analgesic. The panel also recommended parental presence during procedures with adjunctive provision of skin-to-skin care, or non-nutritive sucking when possible., Interpretation: We have generated Kenya's first neonatal analgesic guidelines for routine procedures, which have been adopted by the Kenyan Ministry of Health, and have shown a framework for clinical guideline development that is applicable to other low-income and middle-income health-care settings., Funding: Wellcome Trust Research Programme, and the Africa-Oxford Initiative., (Copyright © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Delivery in a health facility is a key strategy for reducing maternal and neonatal mortality, yet increasing use of facilities has not consistently translated into reduced mortality in low- and middle-income countries. In such countries, many deliveries occur at primary care facilities, where the quality of care is poor. We modeled the geographic feasibility of service delivery redesign that shifted deliveries from primary care clinics to hospitals in six countries: Haiti, Kenya, Malawi, Namibia, Nepal, and Tanzania. We estimated the proportion of women within two hours of the nearest delivery facility, both currently and under redesign. Today, 83-100 percent of pregnant women in the study countries have two-hour access to a delivery facility. A policy of redesign would reduce two-hour access by at most 10 percent, ranging from 0.6 percent in Malawi to 9.9 percent in Tanzania. Relocating delivery services to hospitals would not unduly impede geographic access to care in the study countries. This policy should be considered in low- and middle-income countries, as it may be an effective approach to reducing maternal and newborn deaths.

Aim: There are 2.7 million neonatal deaths annually, 75% of which occur in sub-Saharan Africa and South Asia. Effective treatment of hypoxaemia through tailored oxygen therapy could reduce neonatal mortality and prevent oxygen toxicity., Methods: We undertook a two-part prospective study of neonates admitted to a neonatal unit in Nairobi, Kenya, between January and December 2015. We determined the prevalence of hypoxaemia and explored associations of clinical risk factors and signs of respiratory distress with hypoxaemia and mortality. After staff training on oxygen saturation (SpO 2 ) target ranges, we enrolled a consecutive sample of neonates admitted for oxygen and measured SpO 2 at 0, 6, 12, 18 and 24 h post-admission. We estimated the proportion of neonates outside the target range (≥34 weeks: ≥92%; <34 weeks: 89-93%) with 95% confidence intervals (CIs)., Results: A total of 477 neonates were enrolled. Prevalence of hypoxaemia was 29.2%. Retractions (odds ratio (OR) 2.83, 95% CI 1.47-5.47), nasal flaring (OR 2.68, 95% CI 1.51-4.75), and grunting (OR 2.47, 95% CI 1.27-4.80) were significantly associated with hypoxaemia. Nasal flaring (OR 2.85, 95% CI 1.25-6.54), and hypoxaemia (OR 3.06, 95% CI 1.54-6.07) were significantly associated with mortality; 64% of neonates receiving oxygen were out of range at ≥2 time points and 43% at ≥3 time points., Conclusion: There is a high prevalence of hypoxaemia at admission and a strong association between hypoxaemia and mortality in this Kenyan neonatal unit. Many neonates had out of range SpO 2 values while receiving oxygen. Further research is needed to test strategies aimed at improving the accuracy of oxygen provision in low-resource settings., (© 2017 The Authors Journal of Paediatrics and Child Health published by John Wiley & Sons Australia, Ltd on behalf of Paediatrics and Child Health Division (The Royal Australasian College of Physicians).)

Introduction: Progress has been made in Kenya towards reducing child mortality as part of efforts aligned with the fourth Millennium Development Goal. However, little advancement has been made in reducing mortality among newborns, which now accounts for 45% of all child deaths. The frequently unanticipated nature of neonatal illness, its severity and the high dependency of sick newborns on skilled care make the provision of inpatient hospital services one key component of strategies to improve newborn survival., Methods and Analyses: This project aims to assess the availability and quality of inpatient newborn care in hospitals in Nairobi City County across the public, private and not-for-profit sectors and align this to the estimated need for such services, providing a description of the quantity and quality gaps between capacity and demand. The population level burden of disease will be estimated using morbidity incidence estimates from a literature review applied to subcounty estimates of population-adjusted births, providing a spatially disaggregated estimate of need within the county. This will be followed by a survey of neonatal services across all health facilities providing 24/7 inpatient newborn care in the county. The survey will include: a retrospective audit of admission registers to estimate the usage of facilities and case-mix of patients; a structural assessment of facilities to gain insight into capacity; a questionnaire to nursing staff focusing on the process of delivering key obstetric and neonatal interventions; and a retrospective case audit to assess adherence to guidelines by clinicians., Ethics and Dissemination: This study has been approved by the Kenya Medical Research Institute Scientific and Ethics Review Unit (SSC protocol No.2999). Results will be disseminated: to participating facilities through individualised reports and a joint workshop; to local and national stakeholders through meetings and a summary report; and to the international community through peer-review publication and international meetings., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

A cross-sectional survey was conducted in neonatal and maternity units of five Kenyan district public hospitals. Data for 1 year were obtained: 3999 maternal and 1836 neonatal records plus tallies of maternal deaths, deliveries and stillbirths. There were 40 maternal deaths [maternal mortality ratio: 276 per 100 000 live births, 95% confidence interval (CI): 197-376]. Fresh stillbirths ranged from 11 to 43 per 1000 births. A fifth (19%, 263 of 1384, 95% CI: 11-30%) of the admitted neonates died. Compared with normal birth weight, odds of death were significantly higher in all of the low birth weight (LBW, <2500 g) categories, with the highest odds for the extremely LBW (<1000 g) category (odds ratio: 59, 95% CI: 21-158, p < 0.01). The observed maternal mortality, stillbirths and neonatal mortality call for implementation of the continuum of care approach to intervention delivery with particular emphasis on LBW babies., (© The Author [2015]. Published by Oxford University Press.)

Background: Regular assessment of quality of care allows monitoring of progress towards system goals and identifies gaps that need to be addressed to promote better outcomes. We report efforts to initiate routine assessments in a low-income country in partnership with government., Methods: A cross-sectional survey undertaken in 22 'internship training' hospitals across Kenya that examined availability of essential resources and process of care based on review of 60 case-records per site focusing on the common childhood illnesses (pneumonia, malaria, diarrhea/dehydration, malnutrition and meningitis)., Results: Availability of essential resources was 75% (45/61 items) or more in 8/22 hospitals. A total of 1298 (range 54-61) case records were reviewed. HIV testing remained suboptimal at 12% (95% CI 7-19). A routinely introduced structured pediatric admission record form improved documentation of core admission symptoms and signs (median score for signs 22/22 and 8/22 when form used and not used respectively). Correctness of penicillin and gentamicin dosing was above 85% but correctness of prescribed intravenous fluid or oral feed volumes for severe dehydration and malnutrition were 54% and 25% respectively. Introduction of Zinc for diarrhea has been relatively successful (66% cases) but use of artesunate for malaria remained rare. Exploratory analysis suggests considerable variability of the quality of care across hospitals., Conclusion: Quality of pediatric care in Kenya has improved but can improve further. The approach to monitoring described in this survey seems feasible and provides an opportunity for routine assessments across a large number of hospitals as part of national efforts to sustain improvement. Understanding variability across hospitals may help target improvement efforts.

Objective: An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya., Design: Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data., Setting: Neonatal units of 22 public hospitals., Patients: Neonates aged <7 days., Main Outcome Measures: Quality of care was assessed in terms of availability of basic resources (principally equipment and drugs) and audit of case records for documentation of patient assessment and treatment at admission., Results: All hospitals had oxygen, 19/22 had resuscitation and phototherapy equipment, but some key resources were missing—for example kangaroo care was available in 14/22. Out of 1249 records, 56.9% (95% CI 36.2% to 77.6%) had a standard neonatal admission form. A median score of 0 out of 3 for symptoms of severe illness (IQR 0-3) and a median score of 6 out of 8 for signs of severe illness (IQR 4-7) were documented. Maternal HIV status was documented in 674/1249 (54%, 95% CI 41.9% to 66.1%) cases. Drug doses exceeded recommendations by >20% in prescriptions for penicillin (11.6%, 95% CI 3.4% to 32.8%) and gentamicin (18.5%, 95% CI 13.4% to 25%), respectively., Conclusions: Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: In global health considerable attention is focused on the search for innovations; however, reports tracking their adoption in routine hospital settings from low-income countries are absent., Design and Setting: We used data collected on a consistent panel of indicators during four separate cross-sectional, hospital surveys in Kenya to track changes over a period of 11 years (2002-2012)., Main Outcome Measures: Basic resource availability, use of diagnostics and uptake of recommended practices., Results: There appeared little change in availability of a panel of 28 basic resources (median 71% in 2002 to 82% in 2012) although availability of specific feeds for severe malnutrition and vitamin K improved. Use of blood glucose and HIV testing increased but remained inappropriately low throughout. Commonly (malaria) and uncommonly (lumbar puncture) performed diagnostic tests frequently failed to inform practice while pulse oximetry, a simple and cheap technology, was rarely available even in 2012. However, increasing adherence to prescribing guidance occurred during a period from 2006 to 2012 in which efforts were made to disseminate guidelines., Conclusions: Findings suggest changes in clinical practices possibly linked to dissemination of guidelines at reasonable scale. However, full availability of basic resources was not attained and major gaps likely exist between the potential and actual impacts of simple diagnostics and technologies representing problems with availability, adoption and successful utilisation. These findings are relevant to debates on scaling up in low-income settings and to those developing novel therapeutic or diagnostic interventions.