Child Health Foundation

Background: Mortality among children with acute illness in low-income countries remains high. Referral issues and limitations in emergency care are major challenges to child health and a hypothesis is that care at lower-level facilities delays quality emergency care. This study investigates the extent of care-seeking at health centres prior to hospital admission for sick children, and its association with inpatient mortality in Malawi. Methods: We conducted a retrospective cohort study of children aged 0-12 years admitted to hospitals in Mchinji district, Malawi. Data was collected from September 2019 to April 2020 from one district hospital and three community hospitals. Information was collected from caregivers of admitted children, patient files and ward admission registers. The primary analysis assesses the association between referral from a health centre and in-hospital outcomes using logistic regression. Result: A total of 4926 children were included. The majority (n=4265, 86.6%) had gone straight to hospital without being referred from another health facility. The most common diagnoses were malaria (n= 3345, 67.9%), meningitis or sepsis (n= 1047, 21.3%) and pneumonia (n= 656, 13.3%). Children that were referred from a health centre had a case fatality rate of 5.3%, while those that came straight to the hospital had a case fatality rate of 2.5%. Children who had been referred from a health centre had higher odds of dying (AOR: 2.0, CI 95%: 1.3-3.0), compared to self-referred children. Children with anaemia (AOR: 4.1, CI 95%: 2.7-6.3) and malnutrition (AOR: 6.3, CI 95%: 2.7-14.6) had significantly higher odds of dying, than those without these conditions. Conclusion: Most children admitted to hospital had been taken there without a referral, and these children had better survival than those who had been referred. A better understanding of care-seeking pathways, including referral challenges, may direct interventions to improve timely provision of care for sick children.

ObjectiveTo develop a sepsis care bundle for the initial management of maternal sepsis in low resource settings.DesignModified Delphi process.SettingParticipants from 34 countries.PopulationHealthcare practitioners working in low resource settings (n = 143; 34 countries), members of an expert panel (n = 11) and consultation with the World Health Organization Global Maternal and Neonatal Sepsis Initiative technical working group.MethodsWe reviewed the literature to identify all potential interventions and practices around the initial management of sepsis that could be bundled together. A modified Delphi process, using an online questionnaire and in‐person meetings, was then undertaken to gain consensus on bundle items. Participants ranked potential bundle items in terms of perceived importance and feasibility, considering their use in both hospitals and health centres. Findings from the healthcare practitioners were then triangulated with those of the experts.Main outcome measureConsensus on bundle items.ResultsConsensus was reached after three consultation rounds, with the same items deemed most important and feasible by both the healthcare practitioners and expert panel. Final bundle items selected were: (1) Fluids, (2) Antibiotics, (3) Source identification and control, (4) Transfer (to appropriate higher‐level care) and (5) Monitoring (of both mother and neonate as appropriate). The bundle was given the acronym ‘FAST‐M’.ConclusionA clinically relevant maternal sepsis bundle for low resource settings has been developed by international consensus.Tweetable abstractA maternal sepsis bundle for low resource settings has been developed by international consensus.

Background: The 13-valent pneumococcal conjugate vaccine (PCV13) was introduced in Malawi from November 2011 using a three dose primary series at 6, 10, and 14 weeks of age to reduce Streptococcus pneumoniae-related diseases. To date, PCV13 paediatric coverage in Malawi has not been rigorously assessed. We used household surveys to longitudinally track paediatric PCV13 coverage in rural Malawi. Methods: Samples of 60 randomly selected children (30 infants aged 6 weeks to 4 months and 30 aged 4-16 months) were sought in each of 20 village clinic catchment 'basins' of Kabudula health area, Lilongwe, Malawi between March 2012 and June 2014. Child health information was reviewed and mothers interviewed to determine each child's PCV13 dose status and vaccine timing. The survey was completed six times in 4-8 month intervals. Survey inference was used to assess PCV13 dose coverage in each basin for each age group. All 20 basins were pooled to assess area-wide vaccination coverage over time, by age in months, and adherence to the vaccination schedule. Results: We surveyed a total of 8,562 children in six surveys; 82% were in the older age group. Overall, in age-eligible children, two-dose and three-dose coverage increased from 30% to 85% and 10% to 86%, respectively, between March 2012 and June 2014. PCV13 coverage was higher in the older age group in all surveys. Although it varied by basin, PCV13 coverage was consistently delayed: median ages at first, second and third doses were 9, 15 and 21 weeks, respectively. Conclusion: In our rural study area, PCV13 introduction did not meet the Malawi Ministry of Health one-year three-dose 90% coverage target, but after 2 years reached levels likely to reduce the prevalence of both invasive and non-invasive paediatric pneumococcal diseases. Better adherence to the PCV13 schedule may reduce pneumococcal disease in younger Malawian children.

Targeting Adverse Childhood Experiences by Promoting Resilience Through Anticipatory Guidance: A Quality Improvement Project Purpose: Adverse Childhood Experiences (ACEs) are known to be associated with toxic stress, which can produce life-long consequences in physical and emotional health. Resilience has been well studied and shown to mitigate the effects of toxic stress and ACEs. Strength-based resilience programs have been shown to reduce anxiety and depression, improve school performance, and increase optimism. Pediatricians have been called to promote resilience, yet are challenged with time constraints in busy office practices. Practical tools are needed …

To formulate practice guidelines on rickettsial diseases in children for pediatricians across India. Rickettsial diseases are increasingly being reported from various parts of India. Due to low index of suspicion, nonspecific clinical features in early course of disease, and absence of easily available, sensitive and specific diagnostic tests, these infections are difficult to diagnose. With timely diagnosis, therapy is easy, affordable and often successful. On the other hand, in endemic areas, where healthcare workers have high index of suspicion for these infections, there is rampant and irrational use of doxycycline as a therapeutic trial in patients of undifferentiated fevers. Thus, there is a need to formulate practice guidelines regarding rickettsial diseases in children in Indian context. A committee was formed for preparing guidelines on rickettsial diseases in children in June 2016. A meeting of consultative committee was held in IAP office, Mumbai and scientific content was discussed. Methodology and results were scrutinized by all members and consensus was reached. Textbook references and published guidelines were also used in few instances to make recommendations. Various Indian and international publications pertinent to present study were collated and guidelines were approved by all committee members. Future updates in these guidelines will be dictated by new scientific data in the field of rickettsial diseases in children. Indian tick typhus and scrub typhus are commonly seen rickettsial diseases in India. It is recommended that practicing pediatricians should be well conversant with compatible clinical scenario, suggestive epidemiological features, differential diagnoses and suggestive laboratory features to make diagnosis and avoid over diagnosis of these infections, as suggested in these guidelines. Doxycycline is the drug of choice and treatment should begin promptly without waiting for confirmatory laboratory results.

Childhood is the most important phase in a person’s life. The conducive environment available during this stage of life determines positive psychosocial development of an individual. The current study was conducted among 338 children in difficult circumstances to assess the stress, behaviour problem, adjustment in the areas of home, school, teachers, general and peers and self esteem. The results of the study brought out that, children in difficult circumstances undergo moderate to high stress. These children also exhibited higher behaviour problems which is antisocial and neurotic in nature. The adjustment is poor, especially, in the areas of general adjustment, teacher and school. The self esteem is also found to be average to poor. The results highlight the need for psychosocial interventions which are curative, preventive and promotive in nature to address the problems experienced by the children.