No abstract

Background: There is laboratory evidence of altered immune function in children with malaria. Bacterial infections have been documented to complicate severe forms of malaria. However, it remains unclear whether such infections are attributable to the malaria, other risk factors, or are coincidental. Objective: To determine the prevalence of bacteraemia and urinary tract infections (UTI) in febrile hospitalised children with and without malaria. Design: A cross-sectional survey. Setting: General paediatric wards, Kenyatta National Hospital, Nairobi. Subjects: Children aged between three months and 12 years admitted with an acute febrile illness, with no obvious focus of bacterial infection. Materials and Methods: Using a standardised questionnaire, information on sociodemography, symptomatology, and nutritional status was obtained. Malaria slides, blood and urine cultures were performed on each child. Results: Malaria parasitaemia was present in 158 (60%) of 264 children presenting with acute febrile illness with no obvious focus of bacterial infection. Bacteria were isolated from blood and/or urine of 62 (23%) of all enrolled children. Bacteraemia was prevalent among 11.4% of 158 children with malaria and among 13.2% of 106 without malaria. Gram-positive organisms comprised 28.1% of blood isolates, gram-negative 62.5%, and atypical bacteria 9.4%. UTI was prevalent among 13.3% of 158 children with malaria and 16.0% of 106 children without malaria. Gram-positive organisms comprised 18.4%, gram-negative 78.9%, and atypical bacteria 2.6% of the urine isolates. Presence of malaria parasitaemia was not associated with an increased risk of bacteraemia (OR 0.9, 95% CI [0.4-0.7], or UTI (OR 0.8 95% CI [0.4-1.6] in this study population. Conclusion: Among children hospitalised in Nairobi with fever and no obvious bacterial infective focus, there should be a high index of suspicion for malaria, followed by bacteraemia and UTI. Malaria parasitaemia does not appear to be associated with increased risk of bacterial co-infection.

Notes on contributorsBernard Olayo is a public health specialist and an entrepreneur from Kenya. He is the founder of the Center for Public Health and Development, a non-profit which has designed and developed two successful social enterprises -MediQuip Global (biomedical equipment repair and maintenance solutions) and Hewa Tele (a public-private venture delivering affordable oxygen in remote areas). He has over 14 years of experience managing complex public health programs in resource-limited settings in 15 countries across the globe. He is also a technical team member on several World Bank projects, primarily as a technical advisor to a number of ministries of health. Caroline Kendi Kirigia is a public health practitioner with training as a clinical officer, in project management, and a Masters in public health. Her 13 years of work experience ranges from HIV and TB prevention, care and treatment and team leadership with the University of California San Francisco and the Kenya Medical Research Institute's FACES programme to supporting the development of continuous quality improvement systems with HealthStrat and the Center for Public Health and Development in Kenya where she currently works in programmes. Her current work covers her interest areas of mental health, maternal health, newborn and child health. Jacquie Narotso Oliwa is a paediatrician, clinical epidemiologist, lecturer and a research fellow working on improving case detection of TB in children. She has 10 years of experience in medical education as a trainer for Paediatric TB, paediatric HIV Comprehensive Care Course; Paediatric TB; Paediatric Life support courses. She teaches child health and research methods at the University of Nairobi and has worked in health systems research collaborating with the Kenyan Ministry of Health and government hospitals in various quality improvement projects, pragmatic clinical observational studies trials and conducting systematic reviews. Odero Nicholas Agai is a Consultant Paediatrician and Child Health Specialist with 10 years hands-on experience both in the public and private sectors. He is also affiliated to The Centre for Public Health and Development, Kenya where he is a consultant and is actively involved in training of health care workers on innovative technology that are designed to reduce neonatal and childhood morbidity and mortality.

Background: Severe malnutrition contributes up to 50% of childhood mortality in developing countries is frequently characterised by electrolyte depletion, including low total body phosphate. During therapeutic re-feeding, electrolyte shift from extracellular to intra-cellular compartments may induce hypo-phosphataemia (hypo-P) with resultant increased morbidity and mortality. This biochemical imbalance is under-recognised, and the frequency of this problem among African malnourished children is unclear. Objectives: To determine the magnitude of hypo-phosphataemia in children under five years of age presenting to Kenyatta National Hospital with kwashiorkor and marasmic kwashiorkor and to evaluate the relationship between hypo-phosphataemia and nutritional intervention during the first five days of treatment. Design: Short longitudinal survey. Setting: The General Paediatric wards of the Kenyatta National Hospital (KNH), Nairobi. Subjects: Children under five years of age presenting with kwashiorkor or marasmic kwashiorkor at KNH were recruited into the study. Main outcome measures: Low serum phosphate level (<1.20mmol/l) and patient outcome (survival or death) during the first five days of treatment. Results: One hundred and sixty five children were enrolled between June 2005 and February 2006 of which 107 (64%) had kwashiorkor and 58 (36%) had marasmic kwashiorkor. They were of mean age 20 months (range 3-60), and 95 (58%) were male. The prevalence of hypo-phosphataemia was 86% on admission, increased to 90% and 93% on day one and two respectively, and then declined to 90% by the fourth day. At admission 6% were hypo-phosphataemic, increasing to 18% and 22% on day one and two respectively, and declining to 11% by day four. On admission mean serum phosphate was below normal at 0.91mmol/l, declined significantly to 0.67mmol/l and to a nadir of 0.63mmol/l after the first and second day of treatment respectively, then rose slightly to 0.75mmol/l on the fourth day (p<0.001 comparing each follow-up mean level with the admission level). There was a positive association between severity of nadir serum phosphate level and mortality (p=0.028). There were no deaths among children with normal nadir serum phosphate levels. However, among children with mild, moderate and severe nadir hypo-phosphataemia, 8, 14 and 21% died respectively. Children with dermatosis and hypomagnesaemia showed a trend for association with mortality (p=0.082 and 0.099 respectively). Conclusion: Hypo-phosphataemia is frequent among children with kwashiorkor and marasmic kwashiorkor presenting at KNH. Serum phosphate levels decline significantly during the first two days of nutritional intervention, and severity of hypo-phosphataemia is directly associated with mortality.

Betamethasone administration is associated with a transient return of end-diastolic flow in two thirds of pregnancies complicated by IUGR and umbilical artery absent end-diastolic flow. Persistent absent end-diastolic flow in the umbilical artery after betamethasone administration may identify a subgroup of fetuses with IUGR at further heightened perinatal risk that, as neonates, are more likely to require assisted ventilation and a longer duration of ventilation and supplemental oxygen.