Implementing a Care Pathway for small and nutritionally at-risk infants under six months of age: A multi-country stakeholder consultation

Nutritional vulnerability under the age of 6 months is prevalent in low- and middle-income countries with 20.1% infants underweight, 21.3% wasted and 17.6% stunted in a recent review. A novel Care Pathway for improved management of small and nutritionally at-risk infants under 6 months and their mothers (MAMI) has recently been developed to provide outpatient care at large coverage. We aimed to investigate stakeholders' views on the feasibility of its implementation and to identify barriers and enablers. This was an early stage formative mixed-methods study: an online survey plus in-depth interviews with country-level stakeholders in nutrition and child health from different geographical regions and stakeholder groups. 189 stakeholders from 42 countries responded to the online survey and 14 remote interviews were conducted. Participants expressed an urgent need for improved detection and care for small and nutritionally at-risk infants under 6 months. Whilst they considered the MAMI Care Pathway feasible and relevant, they noted it was largely unknown in their country. The most mentioned implementation barriers were: community-specific needs and health care seeking barriers, health workers' lack of competence in breastfeeding counselling and the absence of a validated anthropometric screening method. Possible enablers for its implementation were: patients' preference for outpatient care, integrating the MAMI care pathway into existing maternal and child health programmes and the possibility of a local pilot project. Adaptation to the local context was considered crucial in further scale-up

Gallstones: Management of the Sickle Cell Child

Gallstone is rare in children; however, sickle cell disease is associated with an increased risk of gallstone formation. We aimed to report particularity of diagnosis and management of gallstones in sickle cell children. We conducted a cross-sectional multicentric study in four hospitals of Dakar, in Senegal, during 18 years. We studied frequency, diagnostic particularities, management, and outcome. Among the 105 pediatric patients managed for gallstones, 87 (82.85%) had sickle cell disease. Among the latter, 18 (17.14%) were asymptomatic. Laparoscopic cholecystectomy was performed in 71 patients (67.62%). Following surgery, sickle cell patients were systematically hospitalized in the intensive care unit for 24 hours. Complications occurred in 7.6% and mortality in 1.9%. Gallstone is frequent in sickle cell children. Its management has good outcomes when taking in account particularities of these patients

Subclinical Cardiac Dysfunction Is Associated With Extracardiac Organ Damages

Background: Several studies conducted in America or Europe have described major cardiac remodeling and diastolic dysfunction in patients with sickle cell disease (SCD). We aimed at assessing cardiac involvement in SCD in sub-Saharan Africa where SCD is the most prevalent.Methods: In Cameroon, Mali and Senegal, SCD patients and healthy controls of the CADRE study underwent transthoracic echocardiography if aged ≥10 years. The comparison of clinical and echocardiographic features between patients and controls, and the associations between echocardiographic features and the vascular complications of SCD were assessed.Results: 612 SCD patients (483 SS or Sβ0, 99 SC, and 19 Sβ+) and 149 controls were included. The prevalence of dyspnea and congestive heart failure was low and did not differ significantly between patients and controls. While left ventricular ejection fraction did not differ between controls and patients, left and right cardiac chambers were homogeneously more dilated and hypertrophic in patients compared to controls and systemic vascular resistances were lower (p < 0.001 for all comparisons). Three hundred and forty nine SCD patients had extra-cardiac organ damages (stroke, leg ulcer, priapism, microalbuminuria or osteonecrosis). Increased left ventricular mass index, cardiac dilatation, cardiac output, and decreased systemic vascular resistances were associated with a history of at least one SCD-related organ damage after adjustment for confounders.Conclusions: Cardiac dilatation, cardiac output, left ventricular hypertrophy, and systemic vascular resistance are associated with extracardiac SCD complications in patients from sub-Saharan Africa despite a low prevalence of clinical heart failure. The prognostic value of cardiac subclinical involvement in SCD patients deserves further studies

Inpatient and outpatient treatment for acute malnutrition in infants under 6 months; a qualitative study from Senegal

Abstract Background Treatment of acute malnutrition in infants under 6 months is a relevant topic regarding the global problem of maternal and child malnutrition. While treatment for older age groups has shifted more towards an outpatient, community based approach, young infants are mostly treated in hospital. This study aims to describe barriers and facilitators for outpatient and inpatient treatment of malnourished infants under 6 months in Senegal. Methods This qualitative descriptive study uses in-depth interviews with health workers and focus group discussions with mothers of malnourished infants, conducted from June to September 2015 in two case clinics. In data analysis, Collins’ 3 key factors for a successful nutrition program were used as a theoretical framework: access, quality of care and community engagement. Results Within Collins’ 3 key factors, 9 facilitators and barriers have emerged from the data. Key factor access: Outpatient care was perceived as more accessible than inpatient concerning distance and cost, given that there is a milk supplement available. Trust could be more easily generated in an outpatient setting. Key factor quality of care: The cup and spoon re-lactation technique was efficiently used in outpatient setting, but needed close supervision. Basic medical care could be offered to outpatients provided that referral of complicated cases was adequate. Health education was more intensive with inpatients, but could be done with outpatients. Key factor community engagement: The community appeared to play a key role in treating malnourished young infants because of its influence on health seeking behaviour, peer support and breastfeeding practices. Conclusions Outpatient care does facilitate access, provided that an affordable milk supplement is available. Quality of care can be guaranteed using an appropriate re-lactation technique and a referral system for complications. The community has the potential to be much engaged, though more attention is required for breastfeeding education. In view of the magnitude of the health problem of young infant malnutrition and its strong relationship with breastfeeding practices, an outpatient community-based treatment approach needs to be considered

Profils épidemiologiques, cliniques et hématologiques de la drépanocytose homozygote SS en phase inter critique chez l’enfant à Ziguinchor, Sénégal

La drépanocytose pose un problème de santé publique au Sénégal. Elle concerne principalement les enfants et les adolescents. L'objectif de notre travail était de déterminer les profils épidémiologiques, cliniques et hématologiques de la drépanocytose homozygote SS dans une cohorte d'enfants suivis à l'hôpital de la paix de Ziguinchor. Il s'agit d'une étude rétrospective portant sur des dossiers d'enfants drépanocytaires. Etaient inclus, les drépanocytaires SS âgés entre 2mois et 21ans, reçus en phase inter critique durant la période d'étude allant du 1er Janvier 2015 au 31 Août 2017. N'étaient pas inclus dans l'étude les hétérozygotes composites (SC, S béta thalassémie). Nous avons colligé 46 dossiers de drépanocytaires SS (20 filles et 26 garçons). L'âge moyen des enfants était de 8,0ans [11mois-21ans]. Environ 1/3 des enfants (39,1%) avaient un âge inférieur ou égal à 5 ans. Il y avait une diversité ethnique avec une prédominance de diola (30,2%) suivi de mandingue (27,9%) et de poular (25,6%). L'âge moyen des enfants à la 1ére crise était de 35,5mois [7-192 mois]. Plus de 1/3 des enfants (41,3%) avaient fait une 1ére crise avant le deuxième anniversaire. Le type de la 1ére crise, qu'avait présenté l'enfant, était dominé par la crise vaso-occlusive (32,6%) suivi du syndrome pied-main (30,4%). Les signes cliniques en phase inter critique étaient la pâleur 95,6%); l'ictère (36,9%) et la splénomégalie (21,7%). A l'hémogramme, le nombre de globules blancs moyen était de 12465 leucocytes/mm3 [5340-26900]. L'hyperleucocytose, supérieure à 10 000 leucocytes/mm3 était retrouvée chez 34 malades (73,9%). La totalité des malades présentait une anémie avec une moyenne 08,6 g/dl [05,7-11,8]. Le taux d'hémoglobine S variait entre 54,6 et 98,4%. Le diagnostic et la prise en charge médicale de la drépanocytose SS sont tardifs à Ziguinchor. Le dépistage néonatal pourrait favoriser une prise en charge précoce dans la région.Mots clés: Drépanocytose SS, phase inter critique, enfantEnglish Title: Epidemiological, clinical and hematological profiles of homozygous sickle cell disease during the intercritical period among children in Ziguinchor, SenegalEnglish AbstractSickle cell disease poses a public health problem in Senegal. It mainly affects children and adolescents. This study aimed to determine the epidemiological, clinical and hematological profiles of homozygous (SS) sickle cell disease in a cohort of children followed-up at the Peace Hospital in Ziguinchor. We conducted a retrospective study of the medical records from children with sickle cell disease. All patients aged between 2 months and 21 years with sickle cell disease SS during the intercritical period, hospitalized during the study period from 1st January 2015 to 31 August 2017 were included in our study. Compound heterozygous patients (SC, S Beta Thalassemia) were not included. We collected 46 medical records of patients with sickle cell disease SS (20 girls and 26 boys). The average age of children was 8,0 years [11 months-21 years]. Approximately 1/3 of children (39.1%) had an age less than or equal to 5 years. There was an ethnic diversity showing a predominance of the Diola (30.2%) followed by the Mandinga (27.9%) and the Poular (25.6%). The average age of children with first crisis was 35,5 months [7-192 months]. More than 1/3 of children (41.3%) had had first crisis before their second anniversary. In the child, first crisis was dominated by vaso-occlusive crisis (32.6%) followed by hand-foot syndrome (30.4%). Clinical signs during the intercritical period were pallor 95.6%), jaundice (36.9%) and splenomegaly (21.7%). Mean white blood cell count was 12465 leucocytes/mm3 [5340-26900]. Hyperleukocytosis greater than 10 000 leucocytes/mm3 was found in 34 patients (73.9%). All patients had anemia with an average hemoglobin of 08,6 g/dl [05,7-11,8]. Hemoglobin S rate ranged between 54.6 and 98.4%. Diagnosis and medical management of sickle cell disease SS are delayed in Ziguinchor. Neonatal screening may lead to improve early management of patients in the region.Keywords: Sickle cell diasease SS, intercritical period, chil