Bogale Worku

Kangaroo Mother Care: 25 Years after

UNLABELLED The components of the Kangaroo Mother Care (KMC) intervention, their rational bases, and their current uses in low-, middle-, and high-income countries are described. KMC was started in 1978 in Bogotá (Colombia) in response to overcrowding and insufficient resources in neonatal intensive care units associated with high morbidity and mortality among low-birthweight infants. The intervention consists of continuous skin-to-skin contact between the mother and the infant, exclusive breastfeeding, and early home discharge in the kangaroo position. In studies of the physiological effects of KMC, the results for most variables were within clinically acceptable ranges or the same as those for premature infants under other forms of care. Body temperature and weight gain are significantly increased, and a meta-analysis showed that the kangaroo position increases the uptake and duration of breastfeeding. Investigations of the behavioral effects of KMC show rapid quiescence. The psychosocial effects of KMC include reduced stress, enhancement of mother-infant bonding, and positive effects on the family environment and the infants cognitive development. CONCLUSION Past and current research has clarified some of the rational bases of KMC and has provided evidence for its effectiveness and safety, although more research is needed to clearly define the effectiveness of the various components of the intervention in different settings and for different therapeutic goals.

Impact of antenatal common mental disorders upon perinatal outcomes in Ethiopia: the P-MaMiE population-based cohort study.

Objectives  To examine the impact of antenatal psychosocial stressors, including maternal common mental disorders (CMD), upon low birth weight, stillbirth and neonatal mortality, and other perinatal outcomes in rural Ethiopia.

Prevalence and predictors of undernutrition among infants aged six and twelve months in Butajira, Ethiopia: the P-MaMiE Birth Cohort.

BackgroundChild undernutrition is a major public health problem in low income countries. Prospective studies of predictors of infant growth in rural low-income country settings are relatively scarce but vital to guide intervention efforts.MethodsA population-based sample of 1065 women in the third trimester of pregnancy was recruited from the demographic surveillance site (DSS) in Butajira, south-central Ethiopia, and followed up until the infants were one year of age. After standardising infant weight and length using the 2006 WHO child growth standard, a cut-off of two standard deviations below the mean defined the prevalence of stunting (length-for-age <-2), underweight (weight-for-age <-2) and wasting (weight-for-length <-2).ResultsThe prevalence of infant undernutrition was high at 6 months (21.7% underweight, 26.7% stunted and 16.7% wasted) and at 12 months of age (21.2% underweight, 48.1% stunted, and 8.4% wasted). Significant and consistent predictors of infant undernutrition in both logistic and linear multiple regression models were male gender, low birth weight, poor maternal nutritional status, poor household sanitary facilities and living in a rural residence. Compared to girls, boys had twice the odds of being underweight (OR = 2.00; 95%CI: 1.39, 2.86) at 6 months, and being stunted at 6 months (OR = 2.38, 95%CI: 1.69, 3.33) and at 12 months of age (OR = 2.08, 95%CI: 1.59, 2.89). Infant undernutrition at 6 and 12 months of age was not associated with infant feeding practices in the first two months of life.ConclusionThere was a high prevalence of undernutrition in the first year of infancy in this rural Ethiopia population, with significant gender imbalance. Our prospective study highlighted the importance of prenatal maternal nutritional status and household sanitary facilities as potential targets for intervention.

The effect of maternal common mental disorders on infant undernutrition in Butajira, Ethiopia: The P-MaMiE study

BackgroundAlthough maternal common mental disorder (CMD) appears to be a risk factor for infant undernutrition in South Asian countries, the position in sub-Saharan Africa (SSA) is unclearMethodsA population-based cohort of 1065 women, in the third trimester of pregnancy, was identified from the demographic surveillance site (DSS) in Butajira, to investigate the effect of maternal CMD on infant undernutrition in a predominantly rural Ethiopian population. Participants were interviewed at recruitment and at two months post-partum. Maternal CMD was measured using the locally validated Self-Reported Questionnaire (score of ≥ six indicating high levels of CMD). Infant anthropometry was recorded at six and twelve months of age.ResultThe prevalence of CMD was 12% during pregnancy and 5% at the two month postnatal time-point. In bivariate analysis antenatal CMD which had resolved after delivery predicted underweight at twelve months (OR = 1.71; 95% CI: 1.05, 2.50). There were no other statistically significant differences in the prevalence of underweight or stunted infants in mothers with high levels of CMD compared to those with low levels. The associations between CMD and infant nutritional status were not significant after adjusting for pre-specified potential confounders.ConclusionOur negative finding adds to the inconsistent picture emerging from SSA. The association between CMD and infant undernutrition might be modified by study methodology as well as degree of shared parenting among family members, making it difficult to extrapolate across low- and middle-income countries.

Perinatal mental distress and infant morbidity in Ethiopia: a cohort study

Objectives (1) To investigate the impact of perinatal common mental disorders (CMD) in Ethiopia on the risk of key illnesses of early infancy: diarrhoea, fever and acute respiratory illnesses (ARI) and (2) to explore the potential mediating role of maternal health behaviours. Design Population-based cohort study. Setting Demographic surveillance site in a predominantly rural area of Ethiopia. Participants 1065 women (86.3% of eligible) in the third trimester of pregnancy were recruited and 954 (98.6%) of surviving, singleton mother–infant pairs were followed up until 2 months after birth. Main exposure measure High levels of CMD symptoms, as measured by the locally validated Self-Reporting Questionnaire (SRQ-20 ≥6), in pregnancy only, postnatally only and at both time-points (‘persistent’). Main outcome measures Maternal report of infant illness episodes in first 2 months of life. Results The percentages of infants reported to have experienced diarrhoea, ARI and fever were 26.0%, 25.0% and 35.1%, respectively. Persistent perinatal CMD symptoms were associated with 2.15 times (95% CI 1.39 to 3.34) increased risk of infant diarrhoea in a fully adjusted model. The strength of association was not affected by including potential mediators: breast feeding practices, hygiene, the infants vaccination status or impaired maternal functioning. Persistent perinatal CMD was not associated with infant ARI or fever after adjusting for confounders. Conclusions Persistent perinatal CMD was associated with infant diarrhoea in this low-income country setting. The observed relationship was independent of maternal health-promoting practices. Future research should further explore the mechanisms underlying the observed association to inform intervention strategies.

Maternal common mental disorders and infant development in Ethiopia: the P-MaMiE Birth Cohort.

BackgroundChronicity and severity of early exposure to maternal common mental disorders (CMD) has been associated with poorer infant development in high-income countries. In low- and middle-income countries (LAMICs), perinatal CMD is inconsistently associated with infant development, but the impact of severity and persistence has not been examined.MethodsA nested population-based cohort of 258 pregnant women was identified from the Perinatal Maternal Mental Disorder in Ethiopia (P-MaMiE) study, and 194 (75.2%) were successfully followed up until the infants were 12 months of age. Maternal CMD was measured in pregnancy and at two and 12 months postnatal using the WHO Self-Reporting Questionnaire, validated for use in this setting. Infant outcomes were evaluated using the Bayley Scales of Infant Development.ResultsAntenatal maternal CMD symptoms were associated with poorer infant motor development (β^ -0.20; 95% CI: -0.37 to -0.03), but this became non-significant after adjusting for confounders. Postnatal CMD symptoms were not associated with any domain of infant development. There was evidence of a dose-response relationship between the number of time-points at which the mother had high levels of CMD symptoms (SRQ ≥ 6) and impaired infant motor development (β^ = -0.80; 95%CI -2.24, 0.65 for ante- or postnatal CMD only, β^ = -4.19; 95%CI -8.60, 0.21 for ante- and postnatal CMD, compared to no CMD; test-for-trend χ213.08(1), p < 0.001). Although this association became non-significant in the fully adjusted model, the β^ coefficients were unchanged indicating that the relationship was not confounded. In multivariable analyses, lower socio-economic status and lower infant weight-for-age were associated with significantly lower scores on both motor and cognitive developmental scales. Maternal experience of physical violence was significantly associated with impaired cognitive development.ConclusionsThe study supports the hypothesis that it is the accumulation of risk exposures across time rather than early exposure to maternal CMD per se that is more likely to affect child development. Further investigation of the impact of chronicity of maternal CMD upon child development in LAMICs is indicated. In the Ethiopian setting, poverty, interpersonal violence and infant undernutrition should be targets for interventions to reduce the loss of child developmental potential.

High load of multi-drug resistant nosocomial neonatal pathogens carried by cockroaches in a neonatal intensive care unit at Tikur Anbessa specialized hospital, Addis Ababa, Ethiopia

BackgroundCockroaches have been described as potential vectors for various pathogens for decades; although studies from neonatal intensive care units are scarce. This study assessed the vector potential of cockroaches (identified as Blatella germanica) in a neonatal intensive care unit setup in Tikur Anbessa Hospital, Addis Ababa, Ethiopia.MethodsA total of 400 Blatella germanica roaches were aseptically collected for five consecutive months. Standard laboratory procedures were used to process the samples.ResultsFrom the external and gut homogenates, Klebsiella oxytoca, Klebsiella pneumoniae, Citrobacter spp. Enterobacter cloacae, Citrobacter diversus, Pseudomonas aeruginosa, Providencia rettgeri, Klebsiella ozaenae, Enterobacter aeruginosa, Salmonella C1, Non Group A streptococcus, Staphylococcus aureus, Escherichia coli, Acinetobacter spp. and Shigella flexneri were isolated. Multi-drug resistance was seen in all organisms. Resistance to up to all the 12 antimicrobials tested was observed in different pathogens.ConclusionCockroaches could play a vector role for nosocomial infections in a neonatal intensive care unit and environmental control measures of these vectors is required to reduce the risk of infection. A high level of drug resistance pattern of the isolated pathogens was demonstrated.

Comparison of Nasal Prongs with Nasal Catheters in the Delivery of Oxygen to Children with Hypoxia

Efficient, inexpensive, and safe methods of oxygen delivery are needed for children with severe pneumonia in developing countries. The objective of this study was to estimate the frequency of complications when nasal catheters or nasal prongs are used to delivery oxygen. Ninety-nine children between 2 weeks and 5 years of age with hypoxia were randomized to receive oxygen via nasal catheter (49 children) or nasal prongs (50 children). There was no difference in the incidence of hypoxaemic episodes or in the oxygen flow rates between the two groups. Mucus production was more of a problem in the catheter group. Nasal blockage, intolerance to the method of administration, and nursing effort were generally higher amongst the catheter group, but these differences were not significant, except for nursing effort, when all age groups were analysed together.

Oxygen administration to hypoxic children in Ethiopia: a randomized controlled study comparing complications in the use of nasal prongs with nasopharyngeal catheters

Oxygen administration is one of the most important therapeutic interventions for a child with severe acute lower respiratory tract infection (ALRI). Inexpensive and efficient methods of oxygen administration are highly desirable in hospitals in developing countries. The objectives of this study were to compare the frequency and nature of complications when nasopharyngeal catheters or nasal prongs are used to deliver oxygen. One hundred and twenty-one children between the ages of 2 weeks and 5 years with hypoxia due to ALRI were randomized to receive oxygen via a catheter (61 children) or via nasal prongs (60 children). The two groups were similar in terms of diagnoses, clinical severity, oxygen saturation on admission and case fatality rates. There was no difference in the incidence of hypoxaemic episodes between the two groups. The oxygen flow rates required on the day of admission for adequate oxygenation (SaO2 > 90%) ranged from 0.8 litres per minute to 1.2 litres per minute. The required oxygen flow rate decreased during the course of treatment. Mucus production was more of a problem in the catheter group, and nasal blockage, intolerance of the method of oxygen administration and nursing effort were generally higher amongst the catheter group, but none of these differences was significant. Ulceration or bleeding of the nose was significantly more common in the catheter group (19.7% vs 6.7%, p < 0.05). Abdominal distension and nasal perforation were not seen in either group. This study suggests that nasal prongs are safer, more comfortable and require less nursing expertise than nasopharyngeal catheters for administration of oxygen to children.

Effect on Neonatal Mortality of Newborn Infection Management at Health Posts When Referral Is Not Possible: A Cluster-Randomized Trial in Rural Ethiopia

Health Extension Workers (HEWs), in general, properly provided antibiotic treatment of possible severe bacterial infections in newborns at the health post level. But only about half of newborns estimated to have infections in the intervention area received treatment by HEWs, and home visits and referrals declined in the final months of the study. Cluster-level analysis suggests a mortality reduction consistent with this level of treatment coverage, although the finding did not reach statistical significance. Health Extension Workers (HEWs), in general, properly provided antibiotic treatment of possible severe bacterial infections in newborns at the health post level. But only about half of newborns estimated to have infections in the intervention area received treatment by HEWs, and home visits and referrals declined in the final months of the study. Cluster-level analysis suggests a mortality reduction consistent with this level of treatment coverage, although the finding did not reach statistical significance. Background: The World Health Organization recently provided guidelines for outpatient treatment of possible severe bacterial infections (PSBI) in young infants, when referral to hospital is not feasible. This study evaluated newborn infection treatment at the most peripheral level of the health system in rural Ethiopia. Methods: We performed a cluster-randomized trial in 22 geographical clusters (11 allocated to intervention, 11 to control). In both arms, volunteers and government-employed Health Extension Workers (HEWs) conducted home visits to pregnant and newly delivered mothers; assessed newborns; and counseled caregivers on prevention of newborn illness, danger signs, and care seeking. Volunteers referred sick newborns to health posts for further assessment; HEWs referred newborns with PSBI signs to health centers. In the intervention arm only, between July 2011 and June 2013, HEWs treated newborns with PSBI with intramuscular gentamicin and oral amoxicillin for 7 days at health posts when referral to health centers was not possible or acceptable to caregivers. Intervention communities were informed of treatment availability at health posts to encourage care seeking. Masking was not feasible. The primary outcome was all-cause mortality of newborns 2–27 days after birth, measured by household survey data. Baseline data were collected between June 2008 and May 2009; endline data, between February 2013 and June 2013. We sought to detect a 33% mortality reduction. Analysis was by intention to treat. (ClinicalTrials.gov registry: NCT00743691). Results: Of 1,011 sick newborns presenting at intervention health posts, 576 (57%) were identified by HEWs as having at least 1 PSBI sign; 90% refused referral and were treated at the health post, with at least 79% completing the antibiotic regimen. Estimated treatment coverage at health posts was in the region of 50%. Post–day 1 neonatal mortality declined more in the intervention arm (17.9 deaths per 1,000 live births at baseline vs. 9.4 per 1,000 at endline) than the comparison arm (14.4 per 1,000 vs. 11.2 per 1,000, respectively). After adjusting for baseline mortality and region, the estimated post–day 1 mortality risk ratio was 0.83, but the result was not statistically significant (95% confidence interval, 0.55 to 1.24; P=.33). Interpretation: When referral to higher levels of care is not possible, HEWs can deliver outpatient antibiotic treatment of newborns with PSBI, but estimated treatment coverage in a rural Ethiopian setting was only around 50%. While our data suggest a mortality reduction consistent with that which might be expected at this level of coverage, they do not provide conclusive results.