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Pneumonia Risk Stratification Scores for Children in Low-Resource Settings: A Systematic Literature Review. Pediatr Infect Dis J 2018; 37:743-748. [PMID: 29278608 PMCID: PMC6014863 DOI: 10.1097/inf.0000000000001883] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Pneumonia is the leading infectious cause of death among children less than 5 years of age. Predictive tools, commonly referred to as risk scores, can be employed to identify high-risk children early for targeted management to prevent adverse outcomes. This systematic review was conducted to identify pediatric pneumonia risk scores developed, validated and implemented in low-resource settings. METHODS We searched CAB Direct, Cochrane Reviews, Embase, PubMed, Scopus and Web of Science for studies that developed formal risk scores to predict treatment failure or mortality among children less than 5 years of age diagnosed with a respiratory infection or pneumonia in low-resource settings. Data abstracted from articles included location and study design, sample size, age, diagnosis, score features and model discrimination. RESULTS Three pediatric pneumonia risk scores predicted mortality specifically, and 2 treatment failure. Scores developed using World Health Organization-recommended variables for pneumonia assessment demonstrated better predictive fit than scores developed using alternative features. Scores developed using routinely collected healthcare data performed similarly well as those developed using clinical trial data. No score has been implemented in low-resource settings. CONCLUSIONS While pediatric pneumonia-specific risk scores have been developed and validated, it is yet unclear if implementation is feasible, what impact, if any, implemented scores may have on child outcomes, or how broadly scores may be generalized. To increase the feasibility of implementation, future research should focus on developing scores based on routinely collected data.
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McCollum ED, Ginsburg AS. Outpatient Management of Children With World Health Organization Chest Indrawing Pneumonia: Implementation Risks and Proposed Solutions. Clin Infect Dis 2018; 65:1560-1564. [PMID: 29020216 PMCID: PMC5850637 DOI: 10.1093/cid/cix543] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Accepted: 06/08/2017] [Indexed: 02/03/2023] Open
Abstract
This Viewpoints article details our recommendation for the World Health Organization Integrated Management of Childhood Illness guidelines to consider additional referral or daily monitoring criteria for children with chest indrawing pneumonia in low-resource settings. We review chest indrawing physiology in children and relate this to the risk of adverse pneumonia outcomes. We believe there is sufficient evidence to support referring or daily monitoring of children with chest indrawing pneumonia and signs of severe respiratory distress, oxygen saturation <93% (when not at high altitude), moderate malnutrition, or an unknown human immunodeficiency virus (HIV) status in an HIV-endemic setting. Pulse oximetry screening should be routine and performed at the earliest point in the patient care pathway as possible. If outpatient clinics lack capacity to conduct pulse oximetry, nutritional assessment, or HIV testing, then we recommend considering referral to complete the evaluation. When referral is not possible, careful daily monitoring should be performed.
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Affiliation(s)
- Eric D McCollum
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine and Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Hooli S, Colbourn T, Lufesi N, Costello A, Nambiar B, Thammasitboon S, Makwenda C, Mwansambo C, McCollum ED, King C. Correction: Predicting Hospitalised Paediatric Pneumonia Mortality Risk: An External Validation of RISC and mRISC, and Local Tool Development (RISC-Malawi) from Malawi. PLoS One 2018; 13:e0193557. [PMID: 29470524 PMCID: PMC5823457 DOI: 10.1371/journal.pone.0193557] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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King C, Boyd N, Walker I, Zadutsa B, Baqui AH, Ahmed S, Islam M, Kainja E, Nambiar B, Wilson I, McCollum ED. Opportunities and barriers in paediatric pulse oximetry for pneumonia in low-resource clinical settings: a qualitative evaluation from Malawi and Bangladesh. BMJ Open 2018; 8:e019177. [PMID: 29382679 PMCID: PMC5829842 DOI: 10.1136/bmjopen-2017-019177] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE To gain an understanding of what challenges pulse oximetry for paediatric pneumonia management poses, how it has changed service provision and what would improve this device for use across paediatric clinical settings in low-income countries. DESIGN Focus group discussions (FGDs), with purposive sampling and thematic analysis using a framework approach. SETTING Community, front-line outpatient, and hospital outpatient and inpatient settings in Malawi and Bangladesh, which provide paediatric pneumonia care. PARTICIPANTS Healthcare providers (HCPs) from Malawi and Bangladesh who had received training in pulse oximetry and had been using oximeters in routine paediatric care, including community healthcare workers, non-physician clinicians or medical assistants, and hospital-based nurses and doctors. RESULTS We conducted six FGDs, with 23 participants from Bangladesh and 26 from Malawi. We identified five emergent themes: trust, value, user-related experience, sustainability and design. HCPs discussed the confidence gained through the use of oximeters, resulting in improved trust from caregivers and valuing the device, although there were conflicts between the weight given to clinical judgement versus oximeter results. HCPs reported the ease of using oximeters, but identified movement and physically smaller children as measurement challenges. Challenges in sustainability related to battery durability and replacement parts, however many HCPs had used the same device longer than 4 years, demonstrating robustness within these settings. Desirable features included back-up power banks and integrated respiratory rate and thermometer capability. CONCLUSIONS Pulse oximetry was generally deemed valuable by HCPs for use as a spot-check device in a range of paediatric low-income clinical settings. Areas highlighted as challenges by HCPs, and therefore opportunities for redesign, included battery charging and durability, probe fit and sensitivity in paediatric populations. TRIAL REGISTRATION NUMBER NCT02941237.
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Affiliation(s)
- Carina King
- Institute for Global Health, University College London, London, UK
| | - Nicholas Boyd
- UCL Institute of Child Health, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Isabeau Walker
- UCL Institute of Child Health, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | | | - Abdullah H Baqui
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Salahuddin Ahmed
- International Center for Maternal and Newborn Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Mazharul Islam
- Department of Anthropology, Shahjalal University of Science and Technology, Sylhet, Bangladesh
| | - Esther Kainja
- Parent and Child Health Initiative, Lilongwe, Malawi
| | - Bejoy Nambiar
- Institute for Global Health, University College London, London, UK
| | | | - Eric D McCollum
- Eudowood Division of Pediatric Respiratory Diseases, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Cox M, Rose L, Kalua K, de Wildt G, Bailey R, Hart J. The prevalence and risk factors for acute respiratory infections in children aged 0-59 months in rural Malawi: A cross-sectional study. Influenza Other Respir Viruses 2017; 11:489-496. [PMID: 28941079 PMCID: PMC5705682 DOI: 10.1111/irv.12481] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2017] [Indexed: 11/30/2022] Open
Abstract
Background Acute Respiratory Infections (ARI) are a leading cause of childhood mortality and morbidity. Malawi has high childhood mortality but limited data on the prevalence of disease in the community. Methods A cross‐sectional study of children aged 0‐59 months. Health passports were examined for ARI diagnoses in the preceding 12 months. Children were physically examined for malnutrition or current ARI. Results 828 children participated. The annual prevalence of ARI was 32.6% (95% CI 29.3‐36.0%). Having a sibling with ARI (OR 1.44, P = .01), increasing household density (OR 2.17, P = .02) and acute malnutrition (OR 1.69, P = .01) were predictors of infection in the last year. The point prevalence of ARI was 8.3% (95% CI 6.8‐10.4%). Risk factors for current ARI were acute‐on‐chronic malnutrition (OR 3.06, P = .02), increasing household density (OR1.19, P = .05) and having a sibling with ARI (OR 2.30, P = .02). Conclusion This study provides novel data on the high prevalence of ARI in Malawi. This baseline data can be used in the monitoring and planning of future interventions in this population.
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Affiliation(s)
- Miriam Cox
- School of Clinical and Experimental Medicine, College of Medicine and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Louis Rose
- School of Clinical and Experimental Medicine, College of Medicine and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Khumbo Kalua
- Department of Ophthalmology, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Gilles de Wildt
- School of Clinical and Experimental Medicine, College of Medicine and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Robin Bailey
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
| | - John Hart
- Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, UK
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Smith AG, Eckerle M, Mvalo T, Weir B, Martinson F, Chalira A, Lufesi N, Mofolo I, Hosseinipour M, McCollum ED. CPAP IMPACT: a protocol for a randomised trial of bubble continuous positive airway pressure versus standard care for high-risk children with severe pneumonia using adaptive design methods. BMJ Open Respir Res 2017; 4:e000195. [PMID: 28883928 PMCID: PMC5531309 DOI: 10.1136/bmjresp-2017-000195] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 05/16/2017] [Accepted: 06/09/2017] [Indexed: 01/24/2023] Open
Abstract
Introduction Pneumonia is a leading cause of mortality among children in low-resource settings. Mortality is greatest among children with high-risk conditions including HIV infection or exposure, severe malnutrition and/or severe hypoxaemia. WHO treatment recommendations include low-flow oxygen for children with severe pneumonia. Bubble continuous positive airway pressure (bCPAP) is a non-invasive support modality that provides positive end-expiratory pressure and oxygen. bCPAP is effective in the treatment of neonates in low-resource settings; its efficacy is unknown for high-risk children with severe pneumonia in low-resource settings. Methods and analysis CPAP IMPACT is a randomised clinical trial comparing bCPAP to low-flow oxygen in the treatment of severe pneumonia among high-risk children 1–59 months of age. High-risk children are stratified into two subgroups: (1) HIV infection or exposure and/or severe malnutrition; (2) severe hypoxaemia. The trial is being conducted in a Malawi district hospital and will enrol 900 participants. The primary outcome is in-hospital mortality rate of children treated with standard care as compared with bCPAP. Ethics and dissemination CPAP IMPACT has approval from the Institutional Review Boards of all investigators. An urgent need exists to determine whether bCPAP decreases mortality among high-risk children with severe pneumonia to inform resource utilisation in low-resource settings. Trial registration number NCT02484183; Pre-results.
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Affiliation(s)
- Andrew G Smith
- Paediatric Critical Care Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Michelle Eckerle
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | | | - Brian Weir
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | | | | | | | - Mina Hosseinipour
- Division of Infectious Disease, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Eric D McCollum
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA.,Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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Nguyen TKP, Nguyen DV, Truong TNH, Tran MD, Graham SM, Marais BJ. Disease spectrum and management of children admitted with acute respiratory infection in Viet Nam. Trop Med Int Health 2017; 22:688-695. [PMID: 28374898 DOI: 10.1111/tmi.12874] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the acute respiratory infection (ARI) disease spectrum, duration of hospitalisation and outcome in children hospitalised with an ARI in Viet Nam. METHODS We conducted a retrospective descriptive study of ARI admissions to primary (Hoa Vang District Hospital), secondary (Da Nang Hospital for Women and Children) and tertiary (National Hospital of Paediatrics in Ha Noi) level hospitals in Viet Nam over 12 months (01/09/2015 to 31/08/2016). RESULTS Acute respiratory infections accounted for 27.9% (37 436/134 061) of all paediatric admissions; nearly half (47.6%) of all children admitted to Hoa Vang District Hospital. Most (64.6%) of children hospitalised with an ARI were <2 years of age. Influenza/pneumonia accounted for 69.4% of admissions; tuberculosis for only 0.3%. Overall 284 (0.8%) children died; most deaths (269/284; 94.7%) occurred at the tertiary referral hospital. The average duration of hospitalisation was 7.6 days (median 7 days). The average direct hospitalisation cost per ARI admission was 157.5 USD in Da Nang Provincial Hospital. In total, 62.6% of admissions were covered by health insurance. CONCLUSION Acute respiratory infection is a major cause of paediatric hospitalisation in Viet Nam, characterised by prolonged hospitalisation for relatively mild disease. There is huge potential to reduce unnecessary hospital admission and cost.
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Affiliation(s)
- T K P Nguyen
- Discipline of Paediatrics and Adolescent Medicine, The Children's Hospital at Westmead, The University of Sydney, Sydney, Australia.,Da Nang Hospital for Women and Children, Da Nang, Viet Nam
| | - D V Nguyen
- Hoa Vang District Hospital, Da Nang, Viet Nam
| | - T N H Truong
- Da Nang Hospital for Women and Children, Da Nang, Viet Nam
| | - M D Tran
- National Hospital of Paediatrics, Ha Noi, Viet Nam
| | - S M Graham
- Centre for International Child Health, Royal Children's Hospital, University of Melbourne and Murdoch Childrens Research Institute, Melbourne, Australia
| | - B J Marais
- Discipline of Paediatrics and Adolescent Medicine, The Children's Hospital at Westmead, The University of Sydney, Sydney, Australia.,Marie Bashir Institute for Infectious Diseases and Biosecurity, The University of Sydney, Sydney, Australia
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McCollum ED, King C, Deula R, Zadutsa B, Mankhambo L, Nambiar B, Makwenda C, Masache G, Lufesi N, Mwansambo C, Costello A, Colbourn T. Pulse oximetry for children with pneumonia treated as outpatients in rural Malawi. Bull World Health Organ 2016; 94:893-902. [PMID: 27994282 PMCID: PMC5153930 DOI: 10.2471/blt.16.173401] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 07/13/2016] [Accepted: 08/15/2016] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To investigate implementation of outpatient pulse oximetry among children with pneumonia, in Malawi. METHODS In 2011, 72 health-care providers at 18 rural health centres and 38 community health workers received training in the use of pulse oximetry to measure haemoglobin oxygen saturations. Data collected, between 1 January 2012 and 30 June 2014 by the trained individuals, on children aged 2-59 months with clinically diagnosed pneumonia were analysed. FINDINGS Of the 14 092 children included in the analysis, 13 266 (94.1%) were successfully checked by oximetry. Among the children with chest indrawing and/or danger signs, those with a measured oxygen saturation below 90% were more than twice as likely to have been referred as those with higher saturations (84.3% [385/457] vs 41.5% [871/2099]; P < 0.001). The availability of oximetry appeared to have increased the referral rate for severely hypoxaemic children without chest indrawing or danger signs from 0% to 27.2% (P < 0.001). In the absence of oximetry, if the relevant World Health Organization (WHO) guidelines published in 2014 had been applied, 390/568 (68.7%) severely hypoxaemic children at study health centres and 52/84 (61.9%) severely hypoxaemic children seen by community health workers would have been considered ineligible for referral. CONCLUSION Implementation of pulse oximetry by our trainees substantially increased the referrals of Malawian children with severe hypoxaemic pneumonia. When data from oximetry were excluded, retrospective application of the guidelines published by WHO in 2014 failed to identify a considerable proportion of severely hypoxaemic children eligible only via oximetry.
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Affiliation(s)
- Eric D McCollum
- Department of Pediatrics, Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins School of Medicine, Rubenstein Building, 200 North Wolfe Street, Baltimore, MD 21287, United States of America
| | - Carina King
- Institute for Global Health, University College London, London, England
| | - Rashid Deula
- Parent and Child Health Initiative Trust, Lilongwe, Malawi
| | | | | | - Bejoy Nambiar
- Institute for Global Health, University College London, London, England
| | | | - Gibson Masache
- Parent and Child Health Initiative Trust, Lilongwe, Malawi
| | | | | | - Anthony Costello
- Institute for Global Health, University College London, London, England
| | - Tim Colbourn
- Institute for Global Health, University College London, London, England
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