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Background. Paediatric septic shock is a subset of sepsis associated with high mortality. Implementing the existing international Surviving Sepsis Campaign Guidelines 2012 (SSCG) have contributed to reduction of mortality in many places but these have not been adopted in our setting. The current study aimed at documenting the practice at a national referral hospital. Methods. A hospital based longitudinal survey carried out among 325 children from September to October 2016. Children aged 0 days (≥37 weeks gestation) to12 years were included. The aim was to determine the prevalence, audit the management and determine the outcome at 72 hours of septic shock among children admitted at the Kenyatta National Hospital (KNH). A standard questionnaire was used for data collection and Surviving Sepsis Guideline 2012 was used as a reference for auditing the management of septic shock. Data was stored in MS-EXCEL and analysed in STATA 12. Results. The prevalence of septic shock was 50 (15.4%), with a median age of 4 months. Septic shock was recognized by the attending clinician in 28 (56%). The level of care to children with septic shock was not to the level recommended by the SSCG 2012. Odds of being diagnosed with septic shock reduced with age (odds ratio 4.38 (1.7–11.0), p=0.002) and no child aged above 60 months age was diagnosed with septic shock. The mortality was 35 (70%) at 72 hours of admission, with a median of 14 hours. Infants had the highest case fatality of 82.6%. It was found that lack of mechanical ventilation, and presence of hypotension at admission were associated with greater mortality (p values of 0.03 and 0.01 respectively). Conclusion. The prevalence rate of septic shock is 15.4% among children admitted at the KNH and is associated with high mortality. The advanced degree of shock contributed to mortality. The level of care at KNH was not to the level of SSCG 2012, and hence the need to include septic shock management guidelines/protocols in our local Kenyan paediatric guideline.

Background. Neonatal sepsis is a leading cause of morbidity and mortality globally. A high index of suspicion is required since features of sepsis are nonspecific. Auditing of antibiotic use is necessary to reduce misuse and minimise development of antibiotic resistance. Objectives. To assess the antibiotic prescribing practices in NBU at KNH against recommended Kenyan guidelines for neonatal sepsis. In addition, outcome within 7 days was described. Methods. This was a prospective audit of 320 neonates over a 2-month period at NBU of KNH. Data were collected using a structured questionnaire, stored in MS-EXCEL, and analysed using STATA. Results. Documentation of perinatal risk factors and clinical features at admission and at the time of change of antibiotics was very poor. The rate of investigations to confirm infection was very low. Blood cultures were done only in 13 (4%) neonates on admission, while complete blood count and C reactive protein were done in 224 (70%) and 198 (62%), respectively. Appropriate antibiotics as per the Kenyan guidelines were prescribed in 313 (97.8%) of neonates on admission. However, these were not stopped at 48-72 hours for the 148 (53.62%) who had improved. Overall mortality was high in neonates at 80 (25%). Majority (55%) died within 48 hours. Mortality was high among preterm neonates; 70 (43.8%) died out of 160. Conclusion. Overall documentation and investigations to confirm infection was poor. The continuation of antibiotics was inappropriate. Overall mortality was high especially in the first 48 hours of admission. To improve documentation, availability of a checklist on admission is recommended.

BACKGROUND: Despite numerous interventions promoting optimal breastfeeding practices in Kenya, pockets of suboptimal breastfeeding practices are documented in Kenya's urban slums. This paper describes cultural and social beliefs and practices that influence breastfeeding in two urban slums in Nairobi, Kenya.METHODS: Qualitative data were collected in Korogocho and Viwandani slums through 10 focus group discussions and 19 in-depth interviews with pregnant, breastfeeding women and community health volunteers and 11 key-informant interviews with community leaders. Interviews were audiotaped, transcribed verbatim, coded in NVIVO and analyzed thematically.RESULTS: Social and cultural beliefs and practices that result to suboptimal breastfeeding practices were highlighted including; considering colostrum as 'dirty' or 'curdled milk', a curse 'bad omen' associated with breastfeeding while engaging in extra marital affairs, a fear of the 'evil eye' (malevolent glare which is believed to be a curse associated with witchcraft) when breastfeeding in public and breastfeeding being associated with sagging breasts. Positive social and cultural beliefs were also identified including the association of breast milk with intellectual development and good child health. The beliefs and practices were learnt mainly from spouses, close relatives and peers.CONCLUSION: Interventions promoting behavior change with regards to breastfeeding should focus on dispelling the beliefs and practices that result to suboptimal breastfeeding practices and to build on the positive ones, while involving spouses and other family members as they are important sources of information on breastfeeding.TRIAL REGISTRATION: ISRCTN83692672: December 2013 (retrospectively registered).

Background: Worldwide access to antiretroviral therapy (ART) in low- and middle-income countries has significantly increased. Although this presents better treatment options for HIV-infected individuals, the challenge of monitoring ART in these settings still remains. Objective: To investigate efficient and cost-effective criteria for assessing ART failure among HIV-1-infected children on first-line ART in resource-limited settings. Study design: Retrospective analysis of 75 HIV-1 vertically infected Kenyan children with a follow-up period of 24 months after initiating ART. Plasma viral load, peripheral CD4+T-cell counts and HIV-1 drug-resistance mutations were monitored biannually. Results: Plasma viral load (VL) was suppressed to undetectable level or more than 1.5 log10 from baseline levels in 53 (70.7%) children within 24 months. VL in the remaining 22 (29.3%) children was not suppressed significantly. Of the 22 children, 21 were infected with HIV-1 strains that developed drug-resistance mutations; 9 within 12 months and 12 between 12 and 24 months. Among the 53 who were successfully treated, VL was suppressed in 33 within 12 months and in 20 between 12 and 24 months. There was no significant difference in VL at baseline and the change of CD4+T-cell counts after initiating ART between those treated successfully and the failure groups. Conclusion: After initiating ART, children may require longer times to achieve complete viral suppression. Plasma viral load testing 24 months after initiating ART could be used to differentiate ART failures among HIV-1 vertically infected children in resource-limited settings. Additionally, drug resistance testing, if affordable, would be helpful in identifying those failing therapy and in choosing second-line regimens. © 2011 Elsevier B.V. All rights reserved.

Background: The kidney is the most damaged organ in asphyxiated full-term infants. The severity of its damage is correlated with the severity of neurological damage. We determined the prevalence of perinatal asphyxia-associated acute kidney injury (AKI).Methods: We conducted a prospective cohort study including 60 full-term neonates admitted at the Kenyatta National Hospital newborn unit (NBU) in Nairobi with hypoxic ischaemic encephalopathy (HIE) from June 2012 to November 2012. Renal function was assessed by measuring serum creatinine on day 3 of life. AKI was defined by a level of creatinine above 133 μmol/l. The degree of neurological impairment was determined daily until patient discharge, death or day 7 of life.Results: Of the 60 infants 36.6% had HIE I, 51.6% HIE II and 11.8% HIE III. The prevalence of AKI was 11.7 %. There was a 15 fold increase risk of developing AKI in HIE III versus HIE I, p=0.034. Mortality rate in perinatal asphyxia associated AKI was 71.4 % with a 24 fold increase risk of death in neonates with AKI, p=0.001.Conclusions: AKI is common and associated with poorer outcomes in perinatal asphyxia. Larger studies need to be done to correlate maternal factors and perinatal asphyxia-associated AKI.Key words: moderate perinatal asphyxia, severe perinatal asphyxia, hypoxic ischaemic encephalopathy, neonatal kidney dysfunction, neonatal neurological dysfunction.

Objectives: Disease progression varies among HIV-1-infected individuals. The present study aimed to explore possible viral and host factors affecting disease progression in HIV-1-infected children. Methods: Since 2000, 102 HIV-1 vertically-infected children have been followed-up in Kenya. Here we studied 29 children (15 male/14 female) who started antiretroviral treatment at 10 years of age (slow progressors; SP). Sequence variations in the HIV-1 gag and nef genes and the HLA class I-related epitopes were compared between the two groups. Results: Based on nef sequences, HIV-1 subtypes A1/D were detected in 62.5%/12.5% of RP and 66.7%/20%of SP, with no significant difference in subtype distribution between groups (p = 0.8). In the ten Nef functional domains, only the PxxP3 region showed significantly greater variation in RP (33.3%) than SP (7.7%, p = 0.048). Gag sequences did not significantly differ between groups. The reportedly protective HLA-A alleles, A∗74:01, A∗32:01 and A∗26, were more commonly observed in SP (50.0%) than RP (11.1%, p = 0.010), whereas the reportedly disease-susceptible HLA-B∗45:01 was more common in RP (33.3%) than SP (7.4%, p = 0.045). Compared to RP, SP showed a significantly higher median number of predicted HLA-B-related 12-mer epitopes in Nef (3 vs. 2, p = 0.037), HLA-B-related 11-mer epitopes in Gag (2 vs. 1, p = 0.029), and HLA-A-related 9-mer epitopes in Gag (4 vs. 1, p = 0.051). SP also had fewer HLA-C-related epitopes in Nef (median 4 vs. 5, p = 0.046) and HLA-C-related 11-mer epitopes in Gag (median 1 vs. 1.5, p = 0.044) than RP. Conclusions: Compared to rapid progressors, slow progressors had more protective HLA-A alleles and more HLA-B-related epitopes in both the Nef and Gag proteins. These results suggest that the host factor HLA plays a stronger role in disease progression than the Nef and Gag sequence variations in HIV-1-infected Kenyan children. © 2015 Saina et al.

Background There are few data on African children infected with nonclade B HIV-1 in endemic settings, which limits generalizations about pathogenesis and progression. Genotypic and phenotypic variations in host immunogenetics and HIV-1 negative factor (nef) accessory protein may influence disease progression and have frequently been characterized in subjects infected with clade B HIV-1. Methods In this descriptive study, we report nef gene sequence variation and host genetic polymorphisms in 32 Kenyan children, including 12 slow progressors. Results Phylogenetic analysis identified HIV-1 clades A, C and D and a recombinant A/D subtype. Grossly defective nef genes or significant changes from relevant clade reference sequences were not identified in children with delayed disease progression. Conclusions nef sequence variations may not be common in perinatally infected African children. Further studies are warranted in HIV-1-infected subjects in settings where infection is endemic.

Background: Meningitis occurs in up to one third of neonates with septicaemia. Diagnosis is difficult due to its non-specificity of signs and symptoms. While neonatal septicaemia is a common problem at Kenyatta National Hospital (KNH), there are no recent data on the incidence and clinical characteristics of neonatal meningitis at the hospital. Objective: To evaluate the prevalence and the bacterial aetiology of meningitis in neonates at the Newborn Unit (NBU) of KNH. Design: Descriptive cross-sectional study. Setting: Newborn Unit of Kenyatta National Hospital, Nairobi, Kenya. Subjects and methods: Lumbar punctures were performed on eighty-four neonates with suspected sepsis based on specified clinical criteria. Cases were defined as meningitis if the cerebrospinal fluid (CSF) was positive for bacteria by Gram stain, aerobic bacterial culture or latex particle agglutination assay. Results: The prevalence of meningitis amongst cases of suspected sepsis was 17.9%. The male:female ratio was l.5:1 mean birth weight 2116.7 grams (1682.2-2551.2) mean gestational age 35.7 weeks (32.6-38.8) and the mean postnatal age was 4.1 days (2.7- 5.4) with none of the parameters being significantly different from those without meningitis. Feed intolerance and lethargy were the most common clinical features, present in 73.3% and 60% of patients with meningitis respectively. Neonates with meningitis had a higher mean CSF protein value (2.67 g/L vs 1.97 g/L, p=0.367) and a significantly higher mean CSF white cell count (21 cells/mL vs 7 cells/mL, p=0.001). The most common aetiological agents were Escherichia coli (46.7%). Group B. Streptococci (26.7%) and Klebsiella pneumonia (13.3%). Most blood and CSF isolates were resistant to ampicillin and gentamicin but showed good in-vitro sensitivities to amikacin, ceturoxime and the third generation cephalosporins (ceftriaxone, ceftazidime and cefotaxime). Blood cultures were positive in only 53.3% of neonates with meningitis. Conclusion: Neonatal bacterial meningitis is an important clinical problem at KNH with a prevalence of 17.9% and amongst cases of suspected sepsis. E. coli and Group B Streptococci were the most common aetiological pathogens. Blood cultures were negative in almost half of the patients with meningitis. Resistance to the commonly employed first-line antibiotics (penicillin and gentamicin) is high and a chance of empirical antibiotic use for neonates with suspected sepsis is recommended.

Background : Survival of patients is regularly used as a measure of the level and appropriateness of medical care provided by institutions. Newborn services have been evaluated in this manner since the 1960s. Though Kenyatta National Hospital has provided neonatal services for over 25 years, no survival data for the low birth weight infants has been published since 1978. Objective : To determine the birthweight specific neonatal survival of infants born weighing less than 2000 grams at Kenyatta National Hospital. Design : A cross sectional survey. Setting : Newborn Unit, Kenyatta National Hospital, Nairobi. Main outcome measures : The proportion of infants surviving the first 28 days of life grouped in the following birthweight categories; below 1000 grams (extremely low birthweight), 1000 - 1499 grams (very low birthweight) and 1500 - 1999 grams (low birthweight). Results : The overall neonatal survival of 163 infants born below 2000 grams was 62.6%. None of the 23 infants born less than 1000 grams survived the neonatal period. Bigger infants fared much better with 68% (n=73) of the 1000 - 1499 and 78% (n=67) of the 1500-1999 gram groups surviving. Survival based on gestational age was also determined. Sixty nine per cent of infants born between 32 and 35 weeks survived while only 27% and 9% of the 28 - 31 weeks and those less than 28 weeks survived respectively. When the patients were analysed for age at death, it was found that over 28% of the deaths occurred within the first day and by the seventh day, more than 70% had died. Less than 30% of the deaths occurred after the first week. The commonest clinical syndromes seen were infection (41%) and respiratory distress (43%). Conclusion : Neonatal survival rates of low birthweight infants are still much lower than those observed in developed countries as far back as the early 1970's. The big proportion of deaths occurring during the first week, and in particular the first day, is due to lack of neonatal intensive care facilities and inadequate obstetric services. (East African Medical Journal: 2002 79(2): 77-79)