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Introduction Recognizing and correcting poor oxygenation early is an essential aspect of paediatric emergency care. The management of hypoxaemia includes establishing an open airway and alveolar ventilatjon, providing supplemental oxygen, [...], Objective To describe the prevalence of hypoxaemia in children admitted to a hospital in Kenya for the purpose of identifying clinical signs of hypoxaemia for emergency triage assessment, and to test the hypothesis that such signs lead to correct identification of hypoxaemia in children, irrespective of their diagnosis. Methods From 2002 to 2005 we prospectively collected clinical data and pulse oximetry measurements for all paediatric admissions to Kilifi District Hospital, Kenya, irrespective of diagnosis, and assessed the prevalence of hypoxaemia in relation to the WHO clinical syndromes of 'pneumonia' on admission and the final diagnoses made at discharge. We used the data collected over the first three years to derive signs predictive of hypoxaemia, and data from the fourth year to validate those signs. Findings Hypoxaemia was found in 977 of 15 289 (6.4%) of all admissions (5% to 19% depending on age group) and was strongly associated with inpatient mortality (age-adjusted risk ratio: 4.5; 95% confidence interval, CI: 3.8-5.3). Although most hypoxaemic children aged ≥ 60 days met the WHO criteria for a syndrome of 'pneumonia' on admission, only 215 of the 693 (31%) such children had a final diagnosis of lower respiratory tract infection (LRTI). The most predictive signs for hypoxaemia included shock, a heart rate < 80 beats per minute, irregular breathing, a respiratory rate > 60 breaths per minute and impaired consciousness. However, 5-15% of the children who had hypoxaemia on admission were missed, and 18% of the children were incorrectly identified as hypoxaemic. Conclusion The syndromes of pneumonia make it possible to identify most hypoxaemic children, including those without LRTI. Shock, bradycardia and irregular breathing are important predictive signs, and severe malaria with respiratory distress is a common cause of hypoxaemia. Overall, however, clinical signs are poor predictors of hypoxaemia, and using pulse oximetry in resource-poor health facilities to target oxygen therapy is likely to save costs. Objectif Decrire la prevalence de l'hypoxemie chez les enfants admis dans un hopital kenyan en vue d'identifier les signes cliniques de l'hypoxemie utilisables pour l'evaluation dans le cadre du triage d'urgence et tester l'hypothese selon laquelle ces signes permettraient une identification correcte des enfants atteints d'hypoxemie, independamment du diagnostic qui doit leur etre affecte. Methodes De 2002 a 2005, nous avons recueilli prospectivement des donnees cliniques et des mesures par oxymetrie pulsee pour l'ensemble des admissions pediatriques a l'hopital de district de Kilifi au Kenya, independamment du diagnostic concernant ces enfants, et evalue la prevalence de l'hypoxemie en relation avec la presence d'un syndrome clinique de type pneumonie selon l'OMS lors de l'admission et du diagnostic final de sortie. Nous avons utilise les donnees collectees sur les trois premieres annees pour determiner les signes predictifs de l'hypoxemie et les donnees de la quatrieme annee pour valider ces signes. Resultats Nous avons releve une hypoxemie chez 977 des 15289 enfants hospitalises (soit 6,4 %, chiffre variant entre 5 a 19 % selon la tranche d'age) et une association forte entre hypoxemie et mortalite des patients hospitalises (rapport de risques ajuste selon l'age: 4,5; intervalle de confiance a 95 %, IC: 3,8-5,3). Si la plupart des enfants hypoxemiques de 60 jours et plus remplissaient, lors de leur admission, les criteres OMS de definition du syndrome de type pneumonie, seuls 215 ales 693 enfants hypoxemiques de 60 jours et plus (31%) ont finalement ete diagnostiques comme atteints d'une infection des voies respiratoires inferieures (IVRI). Parmi les signes les plus predictifs de l'hypoxemie figuraient l'etat de choc, une frequence cardiaque inferieure a 80 battements par minute, une respiration irreguliere, une frequence respiratoire superieure a 60 respirations par minute et un etat de conscience alteree. Neanmoins, 5 a 15 % des enfants hypoxemiques Iors de leur admission n'ont pas ete reperes et 18 % des enfants ont ete identifies a tort comme hypoxemiques. Conclusion Le recours au syndrome de type pneumonie permet d'identifier la plupart des enfants hypoxemiques, y compris ceux atteints d'une IVRI. l'etat de choc, la bradycardie et l'irregularite respiratoire sont des signes predictifs importants et le paludisme grave, avec detresse respiratoire, est une cause courante d'hypoxemie. Globalement neanmoins, les signes cliniques n'ont pas une grande valeur predictive pour l'hypoxemie et li est probable que l'utilisation de l'oxymetrie pulsee par les etablissements de soins qui manquent de moyens pour identifier les patients devant beneficier d'un traitement par l'oxygene permettra de realiser des economies. Objetivo Describir la prevalencia de hipoxemia en ninos ingresados en un hospital de Kenya a fin de identificar los signos clinicos de la misma para un triaje de emergencia, y contrastar la hipotesis de que esos signos permiten detectar correctamente la hipoxemia en los ninos, independientemente del diagnostico. Metodos Entre 2002 y 2005 se reunieron prospectivamente datos clinicos y de oximetria de pulso para todos los ingresos pediatricos en el Hospital de Distrito de Kilifi, Kenya, con independencia del diagnostico, determinandose la prevalencia de hipoxemia en relacion con el sindrome clinico de << neumonia >> definido por la OMS en el momento del ingreso y con el diagnostico final en el momento del alta. Los datos recogidos durante los tres primeros anos se usaron para determinar los signos predictivos de hipoxemia, y los datos reunidos a partir del cuarto ano fueron utilizados para validar esos signos. Resultados Se detecto hipoxemia en 977 de 15 289 (6,4%) ninos ingresados (5%-19% segun el grupo de edad), muy estrechamente asociada a mortalidad hospitalaria (razon de riesgos ajustada por edad: 4,5; intervalo de confianza [IC] del 95%: 3,8-5,3). Aunque la mayoria de los ninos hipoxemicos con [mayor que o igual a] 60 dias de edad cumplian los criterios de la OMS para que pudiera diagnosticarse un sindrome de <> en el momento del ingreso, solo 215 de los 693 (31%) ninos hipoxemicos de esa edad recibieron un diagnostico final de infeccion de las vias respiratorias inferiores (IVRI). Los signos mas predictivos de hipoxemia fueron el choque, una frecuencia cardiaca < 80 latidos por minuto, una respiracion irregular, una frecuencia respiratoria > 60 respiraciones por minuto y un deterioro de la conciencia. Sin embargo, no se detecto la hipoxemia en un 5%-15% de los ninos que la sufrian en el momento del ingreso, y un 18% de los ninos fueron considerados hipoxemicos incorrectamente. Conclusion Los sindromes de neumonia permiten identificar a la mayoria de los ninos hipoxemicos, incluidos los que no presentan IVRI. Un cuadro de choque, la bradicardia y una respiracion irregular son signos predictivos importantes, y la malaria grave con distres respiratorio es una causa comun de hipoxemia. Sin embargo, en general los signos clinicos son poco fiables como factores predictivos de la hipoxemia, y es probable que, en los servicios de salud con recursos escasos, el uso de la oximetria de pulso como criterio para aplicar oxigenoterapia permita ahorrar costos.

Abstract Background Meningitis is notoriously difficult to diagnose in infancy because its clinical features are non-specific. World Health Organization (WHO) guidelines suggest several indicative signs, based on limited data. We aimed to identify indicators of bacterial meningitis in young infants in Kenya, and compared their performance to the WHO guidelines. We also examined the feasibility of developing a scoring system for meningitis. Methods We studied all admissions aged < 60 days to Kilifi District Hospital, 2001 through 2005. We evaluated clinical indicators against microbiological findings using likelihood ratios. We prospectively validated our findings 2006 through 2007. Results We studied 2,411 and 1,512 young infants during the derivation and validation periods respectively. During derivation, 31/1,031 (3.0%) neonates aged < 7 days and 67/1,380 (4.8%) young infants aged 7-59 days (p < 0.001) had meningitis. 90% of cases could be diagnosed macroscopically (turbidity) or by microscopic leukocyte counting. Independent indicators of meningitis were: fever, convulsions, irritability, bulging fontanel and temperature ≥ 39°C. Areas under the receiver operating characteristic curve in the validation period were 0.62 [95%CI: 0.49-0.75] age < 7 days and 0.76 [95%CI: 0.68-0.85] thereafter (P = 0.07), and using the WHO signs, 0.50 [95%CI 0.35-0.65] age < 7 days and 0.82 [95%CI: 0.75-0.89] thereafter (P = 0.0001). The number needed to LP to identify one case was 21 [95%CI: 15-35] for our signs, and 28 [95%CI: 18-61] for WHO signs. With a scoring system, a cut-off of ≥ 1 sign offered the best compromise on sensitivity and specificity. Conclusion Simple clinical signs at admission identify two thirds of meningitis cases in neonates and young infants. Lumbar puncture is essential to diagnosis and avoidance of unnecessary treatment, and is worthwhile without CSF biochemistry or bacterial culture. The signs of Meningitis suggested by the WHO perform poorly in the first week of life. A scoring system for meningitis in this age group is not helpful.

Abstract Background Malaria remains a significant burden in sub-Saharan Africa. However, data on burden of congenital and neonatal malaria is scarce and contradictory, with some recent studies reporting a high burden. Using prospectively collected data on neonatal admissions to a rural district hospital in a region of stable malaria endemicity in Kenya, the prevalence of congenital and neonatal malaria was described. Methods From 1st January 2002 to 31st December 2009, admission and discharge information on all neonates admitted to Kilifi District Hospital was collected. At admission, blood was also drawn for routine investigations, which included a full blood count, blood culture and blood slide for malaria parasites. Results Of the 5,114 neonates admitted during the eight-year surveillance period, blood slide for malaria parasites was performed in 4,790 (93.7%). 18 (0.35%) neonates with Plasmodium falciparum malaria parasitaemia, of whom 11 were admitted within the first week of life and thus classified as congenital parasitaemia, were identified. 7/18 (39%) had fever. Parasite densities were low, ≤50 per μl in 14 cases. The presence of parasitaemia was associated with low haemoglobin (Hb) of 2 10.9 P = 0.001). The case fatality rate of those with and without parasitaemia was similar. Plasmodium falciparum parasitaemia was identified as the cause of symptoms in four neonates. Conclusion Congenital and neonatal malaria are rare in this malaria endemic region. Performing a blood slide for malaria parasites among sick neonates in malaria endemic regions is advisable. This study does not support routine treatment with anti-malarial drugs among admitted neonates with or without fever even in a malaria endemic region.

Abstract Background Most of the global neonatal deaths occur in developing nations, mostly in rural homes. Many of the newborns who receive formal medical care are treated in rural district hospitals and other peripheral health centres. However there are no published studies demonstrating trends in neonatal admissions and outcome in rural health care facilities in resource poor regions. Such information is critical in planning public health interventions. In this study we therefore aimed at describing the pattern of neonatal admissions to a Kenyan rural district hospital and their outcome over a 19 year period, examining clinical indicators of inpatient neonatal mortality and also trends in utilization of a rural hospital for deliveries. Methods Prospectively collected data on neonates is compared to non-neonatal paediatric (≤ 5 years old) admissions and deliveries' in the maternity unit at Kilifi District Hospital from January 1st 1990 up to December 31st 2008, to document the pattern of neonatal admissions, deliveries and changes in inpatient deaths. Trends were examined using time series models with likelihood ratios utilised to identify indicators of inpatient neonatal death. Results The proportion of neonatal admissions of the total paediatric ≤ 5 years admissions significantly increased from 11% in 1990 to 20% by 2008 (trend 0.83 (95% confidence interval 0.45 -1.21). Most of the increase in burden was from neonates born in hospital and very young neonates aged < 7days. Hospital deliveries also increased significantly. Clinical diagnoses of neonatal sepsis, prematurity, neonatal jaundice, neonatal encephalopathy, tetanus and neonatal meningitis accounted for over 75% of the inpatient neonatal admissions. Inpatient case fatality for all ≤ 5 years declined significantly over the 19 years. However, neonatal deaths comprised 33% of all inpatient death among children aged ≤ 5 years in 1990, this increased to 55% by 2008. Tetanus 256/390 (67%), prematurity 554/1,280(43%) and neonatal encephalopathy 253/778(33%) had the highest case fatality. A combination of six indicators: irregular respiration, oxygen saturation of 7 mmol/l predicted inpatient neonatal death with a sensitivity of 81% and a specificity of 68%. Conclusions There is clear evidence of increasing burden in neonatal admissions at a rural district hospital in contrast to reducing numbers of non-neonatal paediatrics' admissions aged ≤ 5years. Though the inpatient case fatality for all admissions aged ≤ 5 years declined significantly, neonates now comprise close to 60% of all inpatient deaths. Simple indicators may identify neonates at risk of death.

Background: Health-related millennium development goals are off track in most of the countries in the sub-Saharan African region. Lack of access to, and low utilization of essential services and high-impact interventions, together with poor quality of health services, may be partially responsible for this lack ofprogress. We explored whether improvement approaches can be applied to increase utilization of antenatal care (ANC), health facility deliveries, prevention of mother-to-child transmission services and adherence to ANC standards of care in a rural district in Kenya. We targeted improvement of ANC services because ANC is a vital point of entry for most high-impact interventions targeting the pregnant mother. Methods: Healthcare workers in 21 public health facilities in Kwale District, Kenya formed improvement teams that met regularly to examine performance gaps in service delivery, identify root causes of such gaps, then develop and implement change ideas to address the gaps. Data were collected and entered into routine government registers by the teams on a daily basis. Data were abstracted from the government registers monthly to evaluate 20 indicators of care quality for improvement activities. For the purposes of this study, aggregate data for the district were collected from the District Health Management Office. Results: The number of pregnant mothers starting ANC within the first trimester and those completing at least four ANC checkups increased significantly (from 41 (8%) to 118 (24%) p=0.002 and from 186 (37%) to 316 (64%) p<0.001, respectively). The proportions of ANC visits in which provision of care adhered to the required standards increased from <40% to 80-100% within three to six months (X2 for trend 4.07, p<0.001). There was also a significant increase in the number of pregnant women delivering in health facilities each month from 164 (33%) to 259 (52%) (p=0.012). Conclusion: Improvement approaches can be applied in rural health care facilities in low-income settings to increase utilization of services and adherence to standards of care. Using the quality improvement methodology to target integrated health services is feasible. Longer follow-up periods are needed to gather more evidence on the sustainability of quality improvement initiatives in low-income countries. [ABSTRACT FROM AUTHOR]