Background Convulsions associated with fever (CAWF), are a frequent medical emergency in children. In the tropics, endemic malaria and bacterial infections are established causes. However, knowledge of the contributions of endemic viral haemorrhagic fevers, particularly Lassa fever(LF) which has multiple lineages of the virus, remains unknown It was hypothesised that LF, may be an unrecognised contributor to CAWF in areas of high disease burden. Objective Determine the prevalence of LF in children with fever, compare seizure characteristics, clinical features and outcomes. Method A prospective case-control study of emergency admissions presenting with fever of 380 C. A positive Lassa virus Reverse-transcription Polymerase Chain Reaction (LV-RT-PCR) defined a diagnosis of LF. Results Three hundred and seventy three febrile children and adolescents were recruited,108 cases (CAWF) compared with 265 controls (fever without convulsions). The prevalence of LF [95% CI] was 3.5% [1.9, 5.7] The prevalence of malaria parasitaemia was significantly higher in CAWF compared with controls (OR [95% CI]=(6.38[2.86, 14.22], p=0.0001 ). There was no significant difference between the prevalence of LF in cases with non-febrile convulsions and their controls ( 2/40 versus 8/94 ) ( Fisher’s exact p=0.759 ). Bleeding was significantly associated with LF in CAWF compared with controls ( Fisher’s exact p=0.008 ). Conclusion LF is an important cause of fever. In this study LF was not significantly associated with CAWF but was a cause of fever presenting with seizures The absence of clear clinical differentiators from other aetiologies of fever without a focus inform the need for a high index of suspicion where the disease is endemic.
AimsDespite the progress made in reducing under five mortality in line with Millennium Development Goal four, the mortality rate remains high worldwide. The most vulnerable time is the neonatal period with 44% of deaths of children under 5 in 2013 occurring within the first 28 days of life. The aim of this analysis is to compare neonatal care in three Kenyan government hospitals to uncover common themes that may be addressed to improve care and potentially reduce Kenyan neonatal mortality. Methods A retrospective review of case notes of newborn unit (NBU) admissions at three government hospitals was conducted over a two month period. Data was collected on demographics, diagnoses, observations and prescriptions. This was done by RCPCH Global Links Programme volunteers and local partners.ResultsA total of 310 neonates were admitted with 221 case notes reviewed (88 excluded due to unavailability of notes and 1 as they were admitted at 2 weeks of age). Performance in each area was varied across hospitals. Overall, 29% of neonates were hypothermic on admission, 4% had blood glucose documented on admission and of those, 22% were hypoglycaemic. The accuracy of prescribing first line antibiotics varied with 0.8%–18% of gentamicin prescriptions being incorrect. Documentation of vitamin K and tetracycline eye ointment administration ranged from 21.6% to 69.7%. Overall mortality rate for the period studied was 14% (range 11%–24%).ConclusionsThis analysis of clinical practice identified both areas of success, and those with potential for improvement. There is a need for ongoing training and education in addition to improvement of the standardised national neonatal admission proforma. Particular areas of strength and weakness in care varied between the hospitals, therefore it may be postulated that by NBU’s sharing experiences, neonatal care could be improved countrywide.
Background After the ebola epidemic, triage systems in many West African hospitals had broken down. This project assessed the impact of a multi-modal quality improvement intervention based on nurse-led assessment and treatment in a 150-bed tertiary paediatric hospital. Methods We reorganised patient flow and outpatient department layout. We delivered nurse training based on WHO Emergency Triage Assessment and Treatment (ETAT) guidelines, and intensive mentoring over three months. Responsibility for initial assessment and treatment was shifted to the nursing staff. All patients presenting between 0800 and 1400 were observed for five consecutive days before intervention, and at three and six months following the start of the intervention. The team observed the triage assessments made by the nurses, and compared them to their own assessments. The team also collected data on patient arrival, triage, assessment and treatment times for all patients. Results Discussion These results suggest that important improvements to paediatric triage and treatment can be delivered in West African hospitals by nurses working in advanced roles.
Aims Healthcare in Myanmar is evolving. This includes the use of evidence based quality improvement, a novel concept for many senior clinicians. Royal College of Paediatrics and Child Health (RCPCH) Global Links Volunteers (GLVs) aimed to deliver audit-based quality improvement teaching to 26 senior local paediatricians (consultants and senior registrars) at 3 sites in central Myanmar. We aimed to assess pre-existing knowledge and post-session motivation to affect change. Methods We devised a half-day simulated quality improvement project (QIP), including an interactive lecture along with simulated data collection and analysis. Each participant thus completed a full QIP cycle. Clinicians then discussed QIP ideas to apply to their own hospitals. One month later they completed a questionnaire to assess the impact of the session. Results Of fifteen respondents, 80% had never experienced quality improvement teaching and over half were unaware of QIP activity ever having occurred in their hospitals. Post-session, 66% of respondents reported they had discussed starting a QIP in their hospital, all whom cited specific examples. 87% reported an intention to start a QIP in the near future and 100% reported feeling more confident regarding the process. The participants seemed motivated, with 100% reporting they felt performing QIPs would make tangible improvements to their hospital, and 100% citing the purpose of a QIP as ‘improvement of patient care’. Despite this none of the respondents had actually started a QIP. Post-session, 33% of respondents reported delivering QIP teaching to local colleagues and thereby encouraging wider participation in quality improvement. They appeared to have retained the information delivered, with 100% correctly explaining the steps of the QIP cycle. Conclusions Interactive practical QIP teaching represents a simple and reproducible model to educate and enthuse senior clinicians with limited previous QIP experience. This enthusiasm appeared to remain 4–6 weeks post teaching. Newly-acquired knowledge had also been disseminated to others. While many respondents reported interest in specific QIPs of their own, none had been realised. This signals both the need and opportunity for on-going partnership to put theory into practice, and continue the evolution of a supportive culture of quality improvement across Myanmar, while further work might assess the barriers to achieving this.
AimsSub-optimal nutrition among children remains a problem across South Asia (SA). Appropriate complementary feeding practices (CFP) can greatly reduce this risk. We aimed to undertake a systematic review of studies assessing CFP in SA children aged 0– 2 years in Bangladesh, India and Pakistan.MethodsSearches undertaken between January 1990 to June 2016; MEDLINE, EMBASE, Global Health, Web of Science, OVID Maternity and Infant Care, BanglaJOL, Cochrane Library, CINAHL, POPLINE and WHO Global Health Library. Eligibility criteria: primary research on CFP in SA children aged 0–2 years and/or their families. Search terms were: ‘children’, ‘feeding’ and ‘Asians’ with their derivatives. Two researchers undertook study selection, data extraction and quality appraisal (EPPI-Centre Weight of Evidence).ResultsFrom 45,712 studies identified, 126 descriptive studies (105 cross-sectional, 11 cohort, 8 qualitative, 1 case-control and 1 mixed studies) were included. 73 from India, 17 Pakistan and 36 Bangladesh. Despite each adopting WHO Infant and Young Children Feeding (IYCF) Guidelines, CFP were sub-optimal in all three countries. In Pakistan, of 15 studies reporting CFP timings, 8 recorded timely initiation (between 6–9 months). Of those reporting dietary diversity, 3 of 9 studies met minimum dietary diversity requirements across 4 of 7 WHO IYCF food groups. 2 of 3 studies observed minimum meal frequency in over 50% of participants. In India 35 of 59 studies reported timely initiation of CFP. 7 of 9 studies noted minimum dietary diversity achieved between 10%–23% of the study population. 5 of 15 studies noted minimum meal frequency achieved between 25%–96% of the study population. In Bangladesh, in 13 of 36 studies timely initiation of CFP ranged from 42%–64%. 3 of 17 studies noted minimum dietary diversity achieved between 19.8%–57.7% of the study population. 1 of 7 studies noted minimum meal frequency achieved between 33%–81% of the study population. Influencing factors included poor education about CFP, cultural beliefs and socioeconomic variables.ConclusionThis is the first SR to evaluate CFP in infants in India, Pakistan and Bangladesh. There is a great need for revision of nationwide child health programmes and campaigns to change health and nutrition behaviour.
Aims Sub-optimal nutrition among children remains a problem across South Asia (SA). Appropriate complementary feeding practices (CFP) can greatly reduce this risk. We aimed to undertake a systematic review of studies assessing CFP in SA children aged 0– 2 years in Bangladesh, India and Pakistan. Methods Searches undertaken between January 1990 to June 2016; MEDLINE, EMBASE, Global Health, Web of Science, OVID Maternity and Infant Care, BanglaJOL, Cochrane Library, CINAHL, POPLINE and WHO Global Health Library. Eligibility criteria: primary research on CFP in SA children aged 0–2 years and/or their families. Search terms were: ‘children’, ‘feeding’ and ‘Asians’ with their derivatives. Two researchers undertook study selection, data extraction and quality appraisal (EPPI-Centre Weight of Evidence). Results From 45,712 studies identified, 126 descriptive studies (105 cross-sectional, 11 cohort, 8 qualitative, 1 case-control and 1 mixed studies) were included. 73 from India, 17 Pakistan and 36 Bangladesh. Despite each adopting WHO Infant and Young Children Feeding (IYCF) Guidelines, CFP were sub-optimal in all three countries. In Pakistan, of 15 studies reporting CFP timings, 8 recorded timely initiation (between 6–9 months). Of those reporting dietary diversity, 3 of 9 studies met minimum dietary diversity requirements across 4 of 7 WHO IYCF food groups. 2 of 3 studies observed minimum meal frequency in over 50% of participants. In India 35 of 59 studies reported timely initiation of CFP. 7 of 9 studies noted minimum dietary diversity achieved between 10%–23% of the study population. 5 of 15 studies noted minimum meal frequency achieved between 25%–96% of the study population. In Bangladesh, in 13 of 36 studies timely initiation of CFP ranged from 42%–64%. 3 of 17 studies noted minimum dietary diversity achieved between 19.8%–57.7% of the study population. 1 of 7 studies noted minimum meal frequency achieved between 33%–81% of the study population. Influencing factors included poor education about CFP, cultural beliefs and socioeconomic variables. Conclusion This is the first SR to evaluate CFP in infants in India, Pakistan and Bangladesh. There is a great need for revision of nationwide child health programmes and campaigns to change health and nutrition behaviour.
Aims Botswana is a country in Southern Africa with a UNAIDS estimated adult HIV prevalence of 25% but a PMTCT program that has limited mother-to-child transmission to an estimated 3%. Haemophilus influenza type B (Hib) vaccination was rolled out nationally in 2011, with WHO estimating coverage of 95% by 2012. This study aims to describe the culture-confirmed causes of meningitis in children in Botswana, a setting with high HIV prevalence and recent introduction of Hib vaccination. Methods We conducted a retrospective laboratory-based surveillance study reviewing paediatric cerebrospinal fluid (CSF) records at the country’s main referral hospital. Microbiology reports from all CSF samples collected from inpatients aged 0–14 years between February 2012 and December 2014 were retrospectively reviewed. Results Over the 3 year period, 1036 samples CSF samples were collected from patients aged 0–14 years. 67 samples were culture positive. Cryptococcus neoformans was the most commonly cultured organism, grown in 27 unique patients. This compared with 10 cases of culture-confirmed Streptococcus pneumoniae and 6 cases of Klebsiella pneumoniae. Haemophilus influenzae was not cultured from any CSF samples during this period. Half of all microbiologically confirmed cases of cryptococcal meningitis occurred in children aged 0–1 years. Conclusion Cryptococcus neoformans was the most common microbiologically confirmed cause of meningitis in Botswana children. It was cultured twice as frequently as Streptococcus pneumoniae, traditionally the most common causative organism of paediatric meningitis. Literature is limited on the epidemiology of paediatric meningitis in settings of high HIV prevalence, although our single-centre study found this to be the predominant isolated pathogen. Following countrywide Hib vaccine rollout, no cases of Hib meningitis were observed during the surveillance period.
IntroductionThe Royal College of Paediatrics and Child Health’s Global Links (GL) Programme, has worked in collaboration with the Kenyan Paediatric Association since 2012. One alliance involved Paediatric trainees from one deanery supporting a hospital in rural Kenya, aiming to implement training and quality improvement projects, providing sustainable improvements and benefit to the hospital and workforce. This link ended in July 2016.MethodsBetween 2013 and 2016, 6 trainees undertook six 6 month placements. Improvements in Neonatal care included; hand hygiene, thermal care, and introduction of CPAP (continuous positive pressure ventilation). In Paediatrics, projects included; introducing regular ETAT (Emergency Treatment, Assessment and Triage) training, evaluation of inpatient nutritional status and improving standards of assessment and documentation according to the Kenyan Basic Paediatric Protocols alongside developing a Paediatric Handbook for the hospital.ResultsIn Neonates, the annual mortality rate fell from 21.6% (2014) to 6.9% (2016 to date). Admissions increased from a mean of 13 to 17 per month. Total mortalities reduced from a mean of 2.75 to 1.2 per month. Hand hygiene compliance improved from 66% (2013) to 93.7% (2015). However in the four months since leaving, the monthly mortality rate was 15%, mean admission numbers - 16 and mean total monthly deaths - 2. In Paediatrics, admission weight documentation increased from 76% (2014) to 94% (2016). Malnutrition status documentation improved from 0% (2014) to 55% (2016).ConclusionsA GL Volunteer presence appears to be associated with significant improvements in the quality of care at this hospital. The unique link with a single deanery enabled close communication between volunteers, allowing each to develop and improve on their predecessors projects. Recent data shows these results are challenging to sustain in a low resource environment with a high staff turnover without volunteer support. Further data is required to evaluate the longevity of any legacy as results may be skewed by variations in pathology. However we hope those trained by the volunteers will transfer their skills and knowledge to their future practice, helping support child health in low resource settings.
Aims A prospective descriptive study was carried out to determine the causes and associated risk factors for childhood death,in a large government hospital in Malawi, Africa. Method: A proforma was written based on the South African Child Healthcare Problem Identifier form, a form devised to audit deaths in order to reduce mortality. We completed the proforma for every death that occurred in the study hospital between December 2015 and August 2016, collecting data on age, sex, HIV status, nutritional status, cause of death, blood and CSF culture, underlying medical factors and any other modifiable factors that may have affected the outcome. Date was collected contemporaneously and from patient files. Results There were 376 inpatient deaths out of 11 086 admissions, giving a mortality rate of 3.4%. There were an additional 58 children brought in dead. One third of deaths (128) occurred in the first 24 hours of admission. There were 186 male deaths and 188 female deaths (n=374). Thirteen percent of deaths (48) occurred in the neonatal period (under 28 days), with a large proportion in the under ones (43%, 159). The most common cause of death was sepsis (85, 23%, of which 28 were neonatal sepsis), followed by lower respiratory tract infection (50, 13%), gastroenteritis (32, 9%),meningitis (29, 8%) and malaria (27,7%). In those children who were brought in dead it was gastroenteritis (14, 24%) followed by malaria (8, 14%) and sepsis (6, 10%). Of the patients with a known HIV status, 106 (38%) were either HIV positive or exposed at birth, compared with 1%–2% of the paediatric population in Malawi. Seventy-six patients (20%) had evidence of malnutrition (marasmus, kwashiorkor or marasmus-kwashiorkor). Conclusion This study highlights the ongoing burden of infectious disease in Malawi, with the top 5 causes of death all being infection related and a very high proportion of deaths in HIV infected or exposed patients. However, it does show a much lower hospital mortality rate then was seen in adults patients in Malawi in 2009 (14.6%) and is comparable to the paediatric South African death rate of 2.4%.
Neonatal sepsis is a significant cause for admissions and mortality in Kenya, accounting for 6% of all deaths in children under 5 years (WHO 2003). The Kenyan Paediatric Association advise that neonates with risk factors should be treated with prophylactic antibiotics to try to prevent them developing sepsis. My experience on the wards was that these guidelines were not being followed, and a number of babies were then being admitted at a later stage with signs of sepsis. Aims To audit the documentation of risk factors for neonatal sepsis and whether guidelines for prophylactic antibiotic use are being followed. Additionally, to audit whether babies are receiving the routine cares that are advised for all neonates, including Vitamin K, Tetracycline eye ointment (TEO) and cord care with chlorhexidine. Methods A retrospective case notes audit of 40 maternal records. Results We found that documentation of risk factors was generally poor. 35% had duration of rupture of membranes recorded, and where prolonged rupture of membranes was noted, prophylactic antibiotics were not given. There was no documentation of maternal temperatures. Two cases were suggestive of chorioamnionitis and no action was taken. Three mothers were treated with IV antibiotics post C-Section but it was unclear whether there were concerns regarding sepsis or if this was routine practice. Two babies were noted to have fevers postnatally. One was treated appropriately and the other did not receive any treatment. In terms of routine cares for neonates, 13% had documentation of vitamin K being administered, 88% had TEO, and 90% were advised on cord care. All mothers had HIV status documented, but for the one HIV positive mother in the sample, there was no record of whether her baby received appropriate treatment. Conclusion Overall, documentation of risk factors was poor and where risk factors or symptoms suggestive of sepsis were noted, they were not always acted on appropriately. Documentation of routine cares was variable, with good use of TEO and cord care, but low numbers for vitamin K. Following teaching and implementation of new documentation forms, we are currently re-auditing practice.
Aims To describe the distribution of Acute Rheumatic Fever (ARF) using deprivation and ethnicity, utilising cases in the Bay of Plenty District Health Board, New Zealand. Background ARF has a significant associated morbidity and mortality. Thorough understanding of epidemiological associations is important for risk assessment and intervention targeting. The Bay of Plenty (BOP) region in New Zealand (NZ) has a high rate of ARF (34/100,000) and is therefore a useful population to study this disease. Method We undertook a retrospective cohort study of those with a principle diagnosis of ARF from 2000–2015 using the NZNHF and Cardiac Society of ANZ criteria 2006–2014. Comparison was made between incidence, ethnicity (Maori, Pacific, European) and deprivation based on residential location (scored using the NZ Deprivation Index 2006 (NZ DEP); 1=least deprived, 10=most deprived). The eastern region (EBOP) was also compared with the western region (WBOP). Data was sourced from medical and 2013 census records. Results 156 cases were identified, average age 12.6 (2–43), 72% were male (n=113). Increased deprivation was associated with increased incidence of ARF; 49% (n=76) of all cases were found in decile 10 (most deprived), and 12.2% (n=19), were in deciles 1–5. Maori ethnicity represented 90% of cases (35x increased risk compared with non-Maori). The WBOP had a lower general deprivation compared with the EBOP (WBOP=5.9, EBOP=7.3) and average ARF case deprivation reflected this (WBOP 7.0, EBOP=9.4). Further, WBOP ARF cases (n=55) showed a more spread distribution (NZ DEP 1–5; WBOP=25%, EBOP=6%). Maori ethnicity maintained a strong association with ARF cases in the WBOP despite lower deprivation (r=0.98). Discussion ARF risk was associated with increased deprivation and Maori ethnicity conferred a high risk independently to deprivation. Our results highlight to professionals working with children, including those in the UK, that although ARF is a disease strongly associated with deprivation, social risk factors may be operating irrespectively and should be considered when determining risk.
1 million neonatal deaths occur annually due to neonatal sepsis, mainly in low-income countries. Low-resource settings present a challenging environment for prompt identification and appropriate management of this condition. Aim To audit the management of neonatal sepsis and to introduce measures to improve its identification and management in a low resource-setting, both among hospital staff and in the wider community. Method A multi-cycle audit was conducted with performance measured against ETAT+ guidelines. Neonatal sepsis admissions were audited on 3 occasions; pre-intervention, at 3 months and 6 months, with multiple interventions continuing throughout this tim Interventions included: Hospital wide teaching to all cadre staff based on ETAT+ principles. Outreach teaching to referring centres Delivery of a daily standardised health talk and the provision of parental leaflet to post-natal mothers. Demonstration of health promotion videos Posters displayed in hospital and community dispensaries. Local staff engaged and motivated by clinical feedback and presentation of audit results. Results 126 patients were audited. Results demonstrate sustained improvement in important parameters Abstract G308 Table 1 Pre-Intervention 3 Months 6 Months Average duration of symptoms (days) 2 3.6 2.3 %Presenting out of hours 22 26 46 Average waiting time for first antibiotic dose (minutes) 266 150 94 %receiving antibiotics within 1 hour 22 53 69 %receiving correct antibiotics 78 94 96 Mortality rate 10% 4.6% 3.7% Conclusion A multi-strategy approach is successful in showing a sustained improvement to the management of neonatal sepsis in a low resource setting
The incidence of Type 1 diabetes (T1DM) in Malawian children is unknown, however as healthcare improves the burden of non-communicable diseases such as diabetes is rapidly increasing. It has been widely believed that diabetic-ketoacidosis (DKA) is an overlooked cause of child mortality due to misdiagnosis and death prior to hospital. The Glycaemic control of Malawian children and adolescents with T1DM has never been evaluated. To improve services for diabetic patients, it is important to audit current practice and outcomes to support quality improvement. This audit aims to assess care processes, access to insulin and current regime, glycaemic control, complications of diabetes, patient factors and socio-economic status. These were audited against the IDF resource limited setting guidelines. A retrospective review of patient notes and diabetic register of the 57 registered patients from 2015–2016. There were 34 males and 23 females ranging from 4–20 years. The median age of diagnosis was 10 years.. Ninety five percent of patients had a HBAlc in the last year. Seventy four percent had had a urine dipstick. Thirty five percent had had an ophthalmology review. Twenty eight percent had had a blood pressure. The median HbA1c for the study population was 11.4%. Overall only 16% of patients had reasonable control. One out of 20 5% had evidence of eye changes related to diabetes. Fifty one percent had microalbuminuria on urine dipstick, 28% had macroalbuminuria. Two patients had neurological complications. The median BMI was 17.6. There were 11 hospital admissions with DKA, four of these were new diagnoses. There was one 1 death due to DKA thought to be due to out of date insulin. There was no significant difference in HBA1c related to economic status. Surprisingly those with higher parental education had worse HBAlc (12 vs 10.9). Patients with access to a fridge also had worse glycaemic control (12 vs 10.6). Children living in rural areas had better HBAlc than those living in urban areas. Glycaemic control was better in children who had the diagnosis of diabetes longer. Conclusion The management of T1DM can be challenging in resource-limited settings. The median HbAlc is comparable to other studies in low resource settings.
AimsThe inpatient management of children with complicated SAM is clinically challenging and mortality rates in Sub-Saharan African malnutrition units remain high despite the presence of WHO treatment guidelines. This study aims to describe the demographic and outcome characteristics of children admitted to a malnutrition unit over a 12 month period in rural Zambia and whether outcomes changed following the introduction of standardised treatment guidelines.MethodsA pre-post intervention design was used. A retrospective case note review was carried out of any child admitted to the paediatric ward from November 2015 – October 2016 who met the WHO criteria for SAM. The management of these children was compared with the WHO recommended ten steps for inpatient management. New treatment guidelines were introduced alongside teaching to medical and nursing staff in May 2016. Data were managed in MS Excel 2010 and analysed using Stata v13.1.ResultsA total of 1930 children were admitted of which 177 (9.2%) had a diagnosis of SAM and remained inpatients for an average of 11 days. The mean age of children admitted with SAM was 26.9 months, 12.3% had HIV and 4.7% had malaria. The overall case fatality rate for the malnutrition unit was 20.9% and of the annual inpatient mortality SAM was a contributor in over a quarter (27%) of deaths. The most common cause of death was sepsis but dehydration was a concurrent diagnosis in 73%. Mortality rates were 23% pre-intervention and 15% post- intervention. When looking at 16 indicators of WHO guideline compliance it was found that only two indicators observed a significant change following intervention. Correct action for these indicators increased and related to iron supplementation (p=<0.001) and F75 volume (p=0.015).ConclusionSAM is a significant cause of childhood inpatient mortality. This preliminary analysis identifies the management of sepsis and dehydration as key areas for further review in our study population. Treatment guidelines can improve compliance in some areas but other factors which influence concordance and the subsequent impact on outcome needs further exploration.
AimsTo achieve and sustain a target of 70% hand hygiene compliance over a three month period.MethodsThe authors spent 6 months working in partnership with local paediatric staff in a District Hospital in Myanmar as part of the RCPCH Global Links Programme. Improving hand hygiene was chosen in response to a high observed rate of Hospital Acquired Infection. Hand hygiene compliance was measured continuously through discrete once-weekly, ward-based observation using a structured template. Commitment to a compliance target of 70% was agreed at the outset among local stakeholders including the cleaners, nurses, doctors and the medical superintendent. Intervention was supported by the WHO multimodal five point strategy and included attaching hand-gel to bed frames throughout the wards, a trial of clinician-carried hand-gel, a poster campaign and structured training of local staff. Weekly data was made visible in the form of a large wall chart and fed back to the team in regular review meetings and ward rounds. This data was used to evaluate the impact of our interventions and to give ‘real time’ performance feedback to the staff groups. Local staff were involved in the collection and display of weekly data and were enabled to take full ownership of this during the project, thereby optimising sustainability.ResultsAt baseline overall hand hygiene compliance was 24%, which is in keeping WHO estimates of below 40% for a developing country. Preliminary data at 4 weeks of follow-up demonstrated a rise in overall hand hygiene compliance to 71% across the paediatric and neonatal wards and across all staff groups. Among nursing staff, hand hygiene compliance rose from 17% at baseline to 55%. For junior doctors, an improvement from 13% to 71% was demonstrated. Among consultants, compliance increased from 36% to 88%.ConclusionUsing these methods we were able to demonstrate an improvement in hand hygiene compliance across all staff groups. Providing that performance feedback is delivered in a culturally sensitive manner, it can be a powerful tool to optimise buy-in and engender a unified team-based approach in this setting.
Acute gastroenteritis (GE) is a major paediatric global health problem and the second commonest cause of death in children under five accounting for an estimated 7,60,000 deaths annually worldwide. There have been significant changes to national guidelines regarding fluid management of children with dehydration secondary to GE in low resource settings. The Clinical Information Network (CIN) is operated by the Kenyan Ministry of Health, Kenyan Medical Research Institute, and Kenyan Paediatric Association (KPA). The CIN facilitates the collection of hospital data with repeated audits and feedback on clinical performance. It highlighted poor performance in assessment and management of dehydration secondary to GE. Aim To improve the management of gastroenteritis including classification of dehydration and appropriate fluid management. Method A series of lecture and scenario based ETAT+ (Emergency Triage Assessment and Treatment plus Admission) sessions encompassing dehydration and fluid therapy secondary to diarrhoea was delivered to all cadres of staff. Management was reinforced with daily bedside teaching based on the principles of ETAT+ and KPA guidelines were displayed in admission and resuscitation areas. Feedback on clinical performance was provided daily. Results Documentation of all key signs of dehydration had improved and 98% (from 94%) of patients had admission dehydration classified as per WHO criteria. In children with severe dehydration aged 1–11 months correct fluid prescription increased to 85% from 45%, with 100% of patients receiving the correct fluid and duration and 85% the correct volume (from 50%). In the 12–59 month group, improvement was demonstrated in correct fluid (100% from 92.8%) duration (85.7% from 71.43%) and volume (100% from 80%) however the correct prescription remained static at 57.14%. In children classified as having no dehydration, ORS was given in 59.3% (previously 32.86%) with 100% of these being prescribed adequately (from 84.6%). A small number of parameters demonstrated deterioration including zinc prescription and classification of bloody or non-bloody diarrhoea. Conclusion Utilising ETAT+ training has improved some important parameters in the management of GE. The data provided by the CIN is invaluable in monitoring performance and directing ongoing improvement strategies.
Consumption of insufficient quantities of food would result to energy deficiency in children, and this can be prevented by early assessment of changes in physical activity. This paper focuses on the effects of general undernutrition on physical activity and on growth, behavior, and cognitive development in Mexico, Uganda, Colombia, and Guatemala. The paper contains studies investigating the influence of undernutrition on physical activity; total energy expenditure; level of physical fitness; influence of physical activity and growth; and relationship of physical activity with behavior and cognitive development. The level of energy expenditure between nutritional groups could be accounted for the smaller size of the body among undernourished children. On the other hand, physiological potential to physically perform work can be maintained by children with mild or moderate malnutrition, but their smaller size limits their output. Lastly, increased physical activity of children receiving food supplementation was associated with exploratory and behavioral differences compared with nonsupplemented children.
