Prof Grace Irimu shows IPS a drip feed bag and a copy of Kenya’s ‘Basic Paediatric Protocols’ as she explains the importance of intravenous treatment in saving the lives of young children affected by acute watery diarrhoea. Credit: Miriam Gathigah/IPS

By Miriam Gathigah
NAIROBI, May 23 2015 (IPS)

Acute watery diarrhoea is a major killer of young children but misunderstanding over the benefits of fluid treatment is preventing many Kenyan parents from resorting to this life-saving technique and threatening to reverse the strides that the country has made in child health.

The 2014 Kenya Demographic and Health Survey, released in April this year, reports that the country’s under-five mortality rate fell to 52 deaths per 1,000 live births in 2014, down from the 74 deaths in 2008-09, but still far from the 32 per 1,000 live births targeted under the Millennium Development Goals (MDGs).“Parents must … understand that rapid fluid treatment is life-saving for children diagnosed with shock or poor blood circulation due to diarrhoea” – Prof Grace Irimu, Associate Professor of Paediatrics, University of Nairobi

The primary treatment for acute watery diarrhoea is rehydration, administered intravenously in the most severe cases of very young children suffering from shock after losing excessively high quantities of body fluids. A fluid bolus – or rapid liquid dose – delivered directly through an intravenous drip allows a much faster delivery than oral rehydration.

However, notes nurse Esther Mayaka at the Jamii Clinic in Mathare, Nairobi, “parents of children brought to hospital with acute watery diarrhoea are refusing to have them put on [drip] fluid treatment and this is a major concern because diarrhoea is a leading killer among children and giving fluids is still the main solution.”

She told IPS that the ongoing rains and floods in many parts of the country “have created a comeback for diseases like cholera whose most telling sign is watery diarrhoea which needs to be managed with fluids.”

In February this year, Kenya’s Director of Medical Services, Dr Nicholas Muraguri, issued a cholera outbreak alert following an increase in cases of acute watery diarrhoea in several counties, including Homa Bay, Migori and Nairobi.

According to Prof Grace Irimu, Associate Professor of Paediatrics at the University of Nairobi, the reluctance to resort to drip fluid treatment has arisen due to misunderstanding generated by a Fluid Expansion As Supportive Therapy (FEAST) study in 2011 to establish whether the bolus technique was the best practice to use among children diagnosed with shock.

The FEAST study, which was conducted among children in Kenya, Tanzania and Uganda, found that fluid boluses increased 48-hour mortality in critically-ill children with poor blood circulation or shock in these resource-limited settings in Africa, but Irimu told IPS that the study excluded diarrhoea and only studied illnesses associated with fever, such malaria and sepsis.

“Parents must therefore understand that rapid fluid treatment is life-saving for children diagnosed with shock or poor blood circulation due to diarrhoea,” she said.

The Kenya Paediatric Association is also trying to set the record straight and, in a statement shared with IPS, the association reiterated that “diarrhoea complicated by severe dehydration is one of the biggest killers of children globally.”

According to the paediatrics association, the FEAST study excluded children with diarrhoea and dehydration because “the value of giving fluids in this group is well known. Giving appropriate fluid therapy is essential.”

Prof Irimu told IPS that the FEAST study had led to a revision of the ‘Basic Paediatric Protocols’, Kenya’s national guidelines for paediatric care, and clauses that address the treatment of diarrhoea were also revised.

Previously, a child diagnosed with shock as a result of diarrhoea would be given fluids in three cycles, every 15 minutes depending on the response. Now, the child receives the fluids in two cycles and if there is no response, health providers are advised to proceed to slower fluid administration where the child is given the amount that the body needs, depending on the level of dehydration.

Meanwhile, the country continues to make strides in dealing with HIV/AIDS – another critical health issue covered by the MDGs – among children. Studies show that the number of children with HIV aged between 18 months and 14 years fell from 184,000 in 2007 to 104,000 in 2012, according to the most recent Kenya Aids Indicator Survey.

However, Prof Joseph Karanja, a reproductive health and HIV/AIDs expert in Nairobi, says that the country can still do better because “through available antiretroviral drugs as a preventive measure among HIV positive mothers, HIV transmission to the infant can be reduced to as low as one percent.”

Dr Pauline Samia, a paediatric neurologist and a board member of the Kenya Paediatric Association, says that there is also a commitment to address conditions that challenge the management of HIV among children such as epilepsy.

“Though research in this area is limited, an estimated 6.7 percent of children with HIV also have epilepsy, with at least 50 percent of children with HIV having central nervous system problems such as delayed development, behavioural challenges and convulsions,” she observes.

Regarding progress in other MDGs, some progress has been made in reducing the prevalence of underweight children less than five years of age, one of the goals set for eradicating extreme hunger and poverty.

The 2014 Kenya Demographic and Health Survey reports that not only has childhood malnutrition declined significantly, from 35 percent in 2008 to the current 26 percent, but the prevalence of underweight children also decreased from 16 percent in 2008 to 11 percent in 2014.

On the front of improving maternal health, the survey says that while maternal mortality remains high at 488 deaths in every 100,000 live births, in the past five years more than three in five births (61 percent) took place in healthcare facilities, a marked improvement compared with the 43 percent in 2008.

Edited by Phil Harris   

She is just 14, but Janida avoids eye contact with others, preferring to look down at the ground and nodding her head if someone tries to engage her in conversation.

Janida (not her real name) was once a sociable and playful child, but that was before she was sexually abused by her stepfather and giving birth to a baby who is now four months old.

Her days marked by trauma and depression, Janida is just one of many girl children in Kenya who have been abused and robbed of their childhood, leaving them emotionally scarred.

“The little girl [Janida] underwent both physical and mental torture,” Teresa Omondi, Deputy Executive Director and Head of Programmes at the Federation of Women Lawyers (FIDA) Kenya, told IPS. ”Her best option was to terminate the pregnancy rather than suffer the mental and physical torture, but she could not afford the cost of a safe abortion.”Many of the induced abortions taking place continue to be unsafe and complications are common” – Teresa Omondi, Federation of Women Lawyers (FIDA) Kenya

Under Article 26 (4) of the Kenyan constitution, “abortion is not permitted unless, in the opinion of a trained health professional, there is need for emergency treatment, or the life or health of the mother is in danger, or if permitted by any other written law.”

In September 2010, Kenya’s Ministry of Health released national guidelines on the medical management of rape or sexual violence – guidelines that allow for termination of pregnancy as an option in the case of conception, but require psychiatric evaluation and recommendation.

Then, in September 2012, the health ministry released standards and guidelines on the prevention and management of unsafe abortions to the extent allowed by Kenyan law, only to withdraw them three months later under unclear circumstances.

According to Omondi, “the law has not yet been fully put into operation and many providers have not been trained to provide safe abortion, meaning many of the induced abortions taking place continue to be unsafe and complications are common.”

The health ministry is responsible for doctors and nurses not being permitted to be trained on providing safe abortion, said Omondi, so “it is ridiculous that while Kenya’s Ministry of Health accepts that post-abortion care is a public health issue regarding numbers, practitioners have their hands tied.”

The issue of unsafe abortions in Kenya hit the headlines in September last year, when Jackson Namunya Tali, a 41-year-old nurse, was sentenced to death by the high court in Nairobi for murder, after the death of both Christine Atieno and her unborn baby in a botched illegal abortion.

Various inter-African meetings attended by Kenya have been held on reducing maternal mortality rates by providing safe abortions, with health ministers agreeing that statistics show that countries that do provide safe abortions have reduced their maternal mortality rates.

In a recent analysis, Saoyo Tabitha Griffith, Reproductive Health Rights Officer at FIDA and an advocate at the High Court of Kenya, said that despite Kenya having adopted a Constitution that affirms among others, women’s rights to reproductive health and access to safe abortion, Kenyan women continue to die from unsafe abortion – a preventable cause of maternal mortality.

For Dr Ong’ech John, a health specialist in Nairobi, perforated uteruses and intestines, heart and kidney failures, anaemia requiring blood transfusion as well as renal problems are just a few of the health complications arising from an abortion that goes wrong.

“Unsafe abortion complications are not just about removal of the products of conception that were not completely removed. One can evacuate but the perforated uterus has to be repaired, or you remove the uterus and it is rotten,” Dr Ong’ech told IPS.

“When the health ministry issued a directive in February this year instructing all health workers, whether from public, private or faith-based organisations, not to participate in any training on safe abortion practices and the use of the medication abortion, many questions were left unanswered,” said Omondi.

A highly respected Kenyan doctor, Dr John Nyamu, spent one year in prison in 2004 after his clinic was raided following the discovery of 15 foetuses on major roads together with planted documents from a hospital he had worked for but had since closed.

Speaking of his ordeal with Mary Fjerstand, a senior clinical advisor at Ipas, a global non-governmental organisation dedicated to ending preventable deaths and disabilities from unsafe abortion, Nyamu said that the publicity surrounding his imprisonment helped people to “realise the magnitude and consequences of unsafe abortion in Kenya; women were dying in great numbers. Before that, abortion was never spoken of in public.”

He went on to say that Kenya wants to achieve the Millennium Development Goal of a 75 percent reduction in maternal mortality, but that “it can’t be achieved if safe abortion is not available.”

A May 2014 World Health Organisation (WHO) updated fact sheet indicates that every day, approximately 800 women die worldwide from preventable causes related to pregnancy and childbirth, with 99 percent of all maternal deaths occurring in developing countries.

Edited by Phil Harris