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Abstract From 2019 to 2022, the For Our Children project gathered a team of Chinese and American pediatricians to explore the readiness of the pediatric workforce in each country to address pressing child health concerns. The teams compared existing data on child health outcomes, the pediatric workforce, and education and combined qualitative and quantitative comparisons centered on themes of effective health care delivery outlined in the World Health Organization Workforce 2030 Report. This article describes key findings about pediatric workload, career satisfaction, and systems to assure competency. We discuss pediatrician accessibility, including geographic distribution, practice locations, trends in pediatric hospitalizations, and payment mechanisms. Pediatric roles differed in the context of each country’s child health systems and varied teams. We identified strengths we could learn from one another, such as the US Medical Home Model with continuity of care and robust numbers of skilled clinicians working alongside pediatricians, as well as China’s Maternal Child Health system with broad community accessibility and health workers who provide preventive care. In both countries, notable inequities in child health outcomes, evolving epidemiology, and increasing complexity of care require new approaches to the pediatric workforce and education. Although child health systems in the United States and China have significant differences, in both countries, a way forward is to develop a more inclusive and broad view of the child health team to provide truly integrated care that reaches every child. Training competencies must evolve with changing epidemiology as well as changing health system structures and pediatrician roles.

The purpose of this policy statement is to update the 2004 American Academy of Pediatrics clinical report and provide enhanced guidance for institutions, administrators, and providers in the development and operation of a pediatric intermediate care unit (IMCU). Since 2004, there have been significant advances in pediatric medical, surgical, and critical care that have resulted in an evolution in the acuity and complexity of children potentially requiring IMCU admission. A group of 9 clinical experts in pediatric critical care, hospital medicine, intermediate care, and surgery developed a consensus on priority topics requiring updates, reviewed the relevant evidence, and, through a series of virtual meetings, developed the document. The intended audience of this policy statement is broad and includes pediatric critical care professionals, pediatric hospitalists, pediatric surgeons, other pediatric medical and surgical subspecialists, general pediatricians, nurses, social workers, care coordinators, hospital administrators, health care funders, and policymakers, primarily in resource-rich settings. Key priority topics were delineation of core principles for an IMCU, clarification of target populations, staffing recommendations, and payment.

BACKGROUND: Noninvasive ventilation (NIV) is increasingly used to manage acute respiratory failure in children, decreasing the need for mechanical ventilation. Safely managing these patients outside of the ICU improves ICU resource use. We measured the impact of a guideline permitting initiation of NIV in an intermediate care unit (IMCU) on ICU bed use. METHODS: A guideline for an NIV trial for acute respiratory failure was implemented in a 10-bed IMCU. The guideline stipulated criteria for initiation and maintenance of NIV. There were 4.5 years of intervention data collected. Baseline data were gathered for patients with acute respiratory failure who were transferred from the IMCU to the ICU for NIV initiation in the 3.25 years before guideline implementation. RESULTS: Three hundred eight patients were included: 101 in the baseline group and 207 in the intervention group. In the intervention group, 143 patients (69%) remained in the IMCU after NIV initiation, and 64 (31%) transferred to the ICU. A total of 656.4 ICU bed-days were saved in the intervention period (3.3 days per patient initiated on NIV in the IMCU). There was a significant decrease in the rate of intubation in the IMCU for patients awaiting ICU transfer (3 patients in the baseline group versus 0 patients in the intervention group; P = .035). CONCLUSIONS: The initiation of NIV in the IMCU for pediatric patients with acute respiratory failure saved ICU bed-days without increasing intubation in the IMCU for patients awaiting transfer. Close monitoring of these critically ill patients is a key component of their safe care.

Large numbers of U.S. physicians and medical trainees engage in hands-on clinical global health experiences abroad, where they gain skills working across cultures with limited resources. Increasingly, these experiences are becoming bidirectional, with providers from low- and middle-income countries traveling to experience health care in the United States, yet the same hands-on experiences afforded stateside physicians are rarely available for foreign medical graduates or postgraduate trainees when they arrive. These physicians are typically limited to observership experiences where they cannot interact with patients in most U.S. institutions. In this article, the authors discuss this inequity in global medical education, highlighting the shortcomings of the observership training model and the legal and regulatory barriers prohibiting foreign physicians from engaging in short-term clinical training experiences. They provide concrete recommendations on regulatory modifications that would allow meaningful short-term clinical training experiences for foreign medical graduates, including the creation of a new visa category, the designation of a specific temporary licensure category by state medical boards, and guidance for U.S. host institutions supporting such experiences. By proposing this framework, the authors hope to improve equity in global health partnerships via improved access to meaningful and productive educational experiences, particularly for foreign medical graduates with commitment to using their new knowledge and training upon return to their home countries.

BackgroundAgeing into adulthood is challenging at baseline, and doing so with a chronic disease can add increased stress and vulnerability. Worldwide, a substantial care gap exists as children transition from care in a paediatric to adult setting. There is no current consensus on safe and equitable healthcare transition (HCT) for patients with chronic disease in resource-denied settings. Much of the existing literature is specific to HIV care. The objective of this narrative review was to summarise current literature related to adolescent HCT not associated with HIV, in low-income and middle-income countries (LMICs) and other resource-denied settings, in order to inform equitable health policy strategies.MethodsA literature search was performed using defined search terms in PubMed and Cumulative Index to Nursing and Allied Health Literature databases to identify all peer-reviewed studies published until January 2020, pertaining to paediatric to adult HCT for adolescents and young adults with chronic disease in resource-denied settings. Following deduplication, 1111 studies were screened and reviewed by two independent reviewers, of which 10 studies met the inclusion criteria. Resulting studies were included in thematic analysis and narrative synthesis.ResultsTwelve subthemes emerged, leading to recommendations which support equitable and age-appropriate adolescent care. Recommendations include (1) improvement of community health education and resilience tools for puberty, reproductive health and mental health comorbidities; (2) strengthening of health systems to create individualised adolescent-responsive policy; (3) incorporation of social and financial resources in the healthcare setting; and (4) formalisation of institution-wide procedures to address community-identified barriers to successful transition.ConclusionLimitations of existing evidence relate to the paucity of formal policy for paediatric to adult transition in LMICs for patients with childhood-onset conditions, in the absence of a diagnosis of HIV. With a rise in successful treatments for paediatric-onset chronic disease, adolescent health and transition programmes are needed to guide effective health policy and risk reduction for adolescents in resource-denied settings.

Background The Board of the Association of Pediatric Program Directors (APPD) partnered with the APPD Global Health Learning Community (GHLC) to establish the APPD Global Pediatric Educator Scholarship. This award seeks to recognize pediatric educators who demonstrate leadership in improving pediatric education in low- and middle-income countries, and provide them with career development opportunities by attending the APPD Spring meeting. Two educators per year have been awarded the scholarship since 2017. Award Evaluation The authors sent survey questions via email and obtained responses from 6 (100%) of the scholarship awardees, 8 (75%) APPD GHLC leadership individuals, and 4 (67%) APPD Board members. Three authors analyzed the responses with consensus achieved on themes. Results Awardees noted learning about educational strategies, academic opportunities through networking, and context for stronger bilateral exchange with partners. APPD leaders noted an expansion of the organization's mission to include global presence. Challenges included program visibility, sustainable funding, and logistics. Suggestions included better incorporation of awardees into APPD membership, longitudinal mentorship, targeted conference navigation, and visits to local academic institutions. Conclusions The APPD Global Educator Scholarship is a replicable model of organizational global outreach that expands the concept of bidirectional exchange to include career sponsorship for global partners.

OBJECTIVES: Medication reconciliation errors on hospital admission can lead to significant patient harm. A pediatric intermediate care unit initiated a quality improvement project and aimed to reduce errors in admission medication reconciliation by 50% in 12 months. METHODS: From August 2017 to December 2018, a multidisciplinary team conducted a quality improvement project with plan-do-study-act methodology. Continuous data collection was achieved by reviewing medications with home caregivers within 18 hours of admission to identify errors. Cycle 1 consisted of nursing training in accurate and thorough medication history documentation. Cycle 2 was aimed at improving data collection. Cycle 3 was aimed at improving pediatric housestaff processes for medication reconciliation. In cycle 4 intervention, the reconciliation process was redesigned to incorporate the bedside nurse reviewing final medication orders with the patient’s home caregivers once the medication reconciliation process was complete. Intermittent maintenance data collection continued for 12 months thereafter. RESULTS: Cycle 1 and 2 interventions resulted in improvement in the medication reconciliation error rate from 9.8% to 4.7%. In cycle 2, the data collection rate improved from 61% to 80% of admissions sustained. Cycle 3 resulted in a further reduction in the medication error rate to 2.9%, which was sustained in cycle 4 and over the 12-month maintenance period. A patient’s number of home medications did not correlate with the error rate. CONCLUSIONS: Reductions in admission medication reconciliation errors can be achieved with staff education on medication history and process for medication reconciliation and with process redesign that incorporates active medication order review as a closed-loop communication with home caregivers.

As North American hospitals serve increasingly diverse patient populations, including recent immigrants, refugees, and returned travelers, all pediatric hospitalists (PHs) require foundational competency in global health, and a subset of PHs are carving out niches focused in global health. Pediatric hospitalists are uniquely positioned to collaborate with low- and middle-income country clinicians and child health advocates to improve the health of hospitalized children worldwide. Using the 2018 WHO standards for improving the quality of care for children and adolescents worldwide, we describe how PHs’ skills align closely with what the WHO and others have identified as essential elements to bring high-quality, sustainable care to children in low- and middle-income countries. Furthermore, North American global health hospitalists bring home expertise that reciprocally benefits their home institutions.

BACKGROUND: Interest in global health (GH) among pediatric residents continues to grow. GH opportunities in pediatric fellowship programs in the United States are poorly described. We aimed to evaluate GH offerings among accredited general and subspecialty pediatric fellowship programs and identify implementation barriers. METHODS: This was a cross-sectional study by pediatric GH educators from the Association of Pediatric Program Directors Global Health Learning Community and the American Board of Pediatrics Global Health Task Force. Fellowship program directors and GH educators at accredited US pediatric fellowship programs were surveyed. Data were analyzed by using descriptive and comparative statistics. RESULTS: Data were obtained from 473 of 819 (57.8%) fellowship programs, representing 111 institutions. Nearly half (47.4%) offered GH opportunities as GH electives only (44.2%) or GH tracks and/or fellowships (3.2%) (GHT/Fs). Pretravel preparation and supervision were variable. Programs offering GH opportunities, compared to those without, were more likely to report that GH training improves fellow education (81.9% vs 38.3%; P < .001) and recruitment (76.8% vs 35.9%; P < .001). Since 2005, 10 programs with GHT/Fs have graduated 46 fellows, most of whom are working in GH. Of those with GHT/Fs, 71% believe national accreditation of GH fellowships would define minimum programmatic standards; 64% believe it would improve recruitment and legitimize GH as a subspecialty. CONCLUSIONS: GH experiences are prevalent in accredited US pediatric fellowship programs, and programs offering GH perceive that these opportunities improve fellow education and recruitment. Responses suggest that standards for GH opportunities during fellowship would be useful, particularly regarding pretravel preparation and mentorship for trainees.

* Abbreviations: AAP — : American Academy of Pediatrics ABP — : American Board of Pediatrics APPD — : Association of Pediatric Program Directors ETC — : Education and Training Committee GH — : global health GHLC — : Global Health Learning Community GHTF — : Global Health Task Force LMIC — : low- and middle-income country SOICH — : Section on International Child Health Pediatric trainees are increasingly seeking global health (GH) educational opportunities, with ∼1 in 4 participating in a GH elective during residency.1,2 Training programs have responded to this demand: surveys suggest that ∼58% of residency and 47% of fellowship training programs offer GH electives.3,4 In accordance with best practices pertaining to short-term GH electives, many programs are attempting to build GH training opportunities beyond electives, including longitudinal GH curricula at their respective institutions, predeparture preparation training, postreturn debriefing, and global training partnerships.1,2,4–11 Concomitantly, educators are recognizing that all trainees, not just those planning to work abroad, need to learn about GH-related topics. The “local global health” framework12 highlights that diseases do not respect borders, resource limitation is not unique to low- and middle-income countries (LMICs), and core skills are necessary for all trainees caring for patients and families from (and going to) diverse settings. These skills include using interpreters effectively, caring for immigrants and travelers, employing … Address correspondence to Nicole E. St Clair, MD, Department of Pediatrics, University of Wisconsin–Madison School of Medicine and Public Health, H4/477 Mailcode 4108, 600 Highland Ave, Madison, WI 53792-4108. E-mail: nstclair{at}wisc.edu

BACKGROUND: Global health (GH) offerings by pediatric residency programs have increased significantly, with 1 in 4 programs indicating they offer a GH track. Despite growth of these programs, there is currently no widely accepted definition for what comprises a GH track in residency. METHODS: A panel of 12 pediatric GH education experts was assembled to use the Delphi method to work toward a consensus definition of a GH track and determine essential educational offerings, institutional supports, and outcomes to evaluate. The panelists completed 3 rounds of iterative surveys that were amended after each round on the basis of qualitative results. RESULTS: Each survey round had 100% panelist response. An accepted definition of a GH track was achieved during the second round of surveys. Consensus was achieved that at minimum, GH track educational offerings should include a longitudinal global child health curriculum, a GH rotation with international or domestic underserved experiences, predeparture preparation, preceptorship during GH electives, postreturn debrief, and scholarly output. Institutional supports should include resident salary support; malpractice, evacuation, and health insurance during GH electives; and a dedicated GH track director with protected time and financial and administrative support for program development and establishing partnerships. Key outcomes for evaluation of a GH track were agreed on. CONCLUSIONS: Consensus on the definition of a GH track, along with institutional supports and educational offerings, is instrumental in ensuring consistency in quality GH education among pediatric trainees. Consensus on outcomes for evaluation will help to create quality resident and program assessment tools.

The following is declared in the World Health Organization Workforce 2030 report: > Mere availability of health workers is not sufficient: only when they are equitably distributed and accessible by the population, when they possess the required competency, and are motivated and empowered to deliver quality care that is appropriate and acceptable to the sociocultural expectations of the population, and when they are adequately supported by the health system, can theoretical coverage translate into effective service coverage. 1 In their article titled “Characteristics and Workload of Pediatricians in China,” Zhang et al2 begin to measure many of those necessary facets for a functioning pediatric workforce and raise some interesting questions. In China, some individuals with only 3 years of postsecondary education are referred to as pediatricians, which is significantly less training than the norm in most other countries. This does not mean those individuals do not have an important contribution to make; indeed, task shifting, particularly of health care provision for predictable and simple disorders, is an important means of allowing providers to work at the “top of … Address correspondence to Christiana M. Russ, MD, DTMH, FAAP, Division of Medical Critical Care, Boston Children’s Hospital, 300 Longwood Ave, 11S Main, Boston, MA 02115. E-mail: christiana.russ{at}childrens.harvard.edu

Purpose of review This paper provides a brief overview of the current landscape of global child health and the impact of social determinants on the world's children. In the United States (US), global child health (GCH) has increasingly been highlighted as a priority area by national organizations, such as the National Academy of Medicine and American Academy of Pediatrics, as well as individual pediatricians committed to ensuring the health of all children regardless of geographic location. Although GCH is commonly used to refer to the health of children outside of the US, here, we highlight the recent call for GCH to also include care of US vulnerable children. Many of the lessons learned from abroad can be applied to pediatrics domestically by addressing social determinants that contribute to health disparities. Recent findings Using the 'three-delay' framework, effective global health interventions target delays in seeking, accessing, and/or receiving adequate care. In resource-limited, international settings, novel health system strengthening approaches, such as peer groups, community health workers, health vouchers, cultural humility training, and provision of family-centered care, can mitigate barriers to healthcare and improve access to medical services. Summary The creative use of limited resources for pediatric care internationally may offer insight into effective strategies to address health challenges that children face here in the US. The growing number of child health providers with clinical experience in resource-limited, low-income countries can serve as an unforeseen yet formidable resource for improving pediatric care in underserved US communities.

Introduction Global health (GH) tracks are becoming increasingly common in pediatric residency and fellowship programs around the country. A recent Delphi process 1 identified a consensus definition for GH tracks within pediatric residency programs, determined key educational and institutional components, and established target outcomes for programmatic evaluation. The aim of this project was to develop and validate a set of standardized surveys to be used as an evaluation tool for pediatric GH tracks. Methods The authors, all committee members of the American Association of Pediatric Program Directors Global Health Learning Community (APPD GHLC), created a set of standardized surveys to serve as an evaluation tool to facilitate comparison of resources and outcomes among GH tracks within pediatric residency programs. Based on consensus outcomes identified in a previous Delphi, 1 the authors created surveys for four stakeholder groups: (1) current GH track residents, (2) GH track alumni, (3) GH track directors, and (4) GH track host sites/partners. Surveys sought to assess resident perceptions, educational outcomes, influence of tracks on career paths, and the human and monetary programmatic resources required to run tracks. As initial validation steps, the authors developed survey questions based on previously identified outcomes and input from stakeholders. The survey was reviewed by a survey methodologist to support content validity. To collect evidence of response process validity, structured cognitive interviews were conducted for each survey with 1 or more stakeholder group members with further edits incorporated. Results The resulting surveys will be piloted among three pediatric residency GH tracks in Spring 2020 with subsequent analysis of pilot data planned to assess reliability and further construct validity. Data will be used by individual GH tracks for programmatic improvement and will allow comparison among GH tracks for future research. Conclusion This is the first standardized tool for evaluating GH tracks within pediatric residency programs. The evaluation tool will be available on the APPD GHLC website.

Appeals for health equity call for departments of pediatrics to improve the health of all children including those from underserved communities in North America and around the world. Consequently, North American (NA) departments of pediatrics have a role in global child health (GCH) which focuses on providing health care to underserved children worldwide. In this review, we describe how NA departments of pediatrics can collaboratively engage in GCH education, clinical practice, research, and advocacy and summarize best practices, challenges, and next steps for engaging in GCH in each of these areas. For GCH in low- and middle-income countries (LMICs), best practices start with the establishment of ethical, equitable, and collaborative partnerships with LMIC communities, organizations, and institutions engaged in GCH who are responsible for the vast majority of work done in GCH. Other best practices include adequate preparation of trainees and clinicians for GCH experiences; alignment with local clinical and research priorities; contributions to local professional development and ongoing monitoring and evaluation. Challenges for departments include generating funding for GCH activities; recruitment and retention of GCH-focused faculty members; and challenges meeting best practices, particularly adequate preparation of trainees and clinicians and ensuring mutual benefit and reciprocity in NA–LMIC collaborations. We provide examples of how departments have overcome these challenges and suggest next steps for development of the role of NA departments of pediatrics in GCH. Collaborative implementation of best practices in GCH by LMIC–NA partnerships can contribute to reductions of child mortality and morbidity globally.

Background In the past decade, interest in global health (GH) among graduating pediatric residents has grown. The availability of these opportunities can influence their ranking of fellowship programs. Current GH opportunities in pediatric fellowship programs in the United States (US) are not well described. Methods This was a cross-sectional study by pediatric GH educators including representatives from the Association of Pediatric Program Directors (APPD) GH Learning Community and the American Board of Pediatrics. Program directors and GH educators at US pediatric fellowship programs were surveyed using REDCap®. Data were analyzed using standard descriptive statistics. Results Data were collected from 473 of 819 (58%) eligible US pediatric fellowship programs representing 111 institutions across all APPD regions and ABP subspecialties. 47% offered GH training opportunities as either GH electives (n=209, 44%) or formal GH fellowships (n=15, 3%). There was variable pretravel preparation (Table 1) and supervision for research projects, with almost 20% of programs indicating a lack of GH faculty on fellows' scholarship oversight committees. Programs offering any GH opportunities, compared to those without, were more likely to report that available GH training improves fellow education (82% vs. 38%, p Conclusions GH experiences are an integral part of many US fellowship programs, and programs offering GH perceive that these opportunities improve the education and recruitment of fellows. Data suggest that standards for GH opportunities during fellowship training would be useful, particularly pertaining to pre-travel preparation, supervision, and mentorship for trainees.

BACKGROUND: Hospitalized children have a wide range of acuity and risk of decompensation. The objective of this study was to determine where pediatric patients are triaged when they present to pediatric hospitals needing intense monitoring and nursing care, but do not require invasive monitoring or technology. METHODS: We completed a telephone survey of pediatric hospitals in the United States with at least 2 non-neonatal pediatric wards and at least 50 acute inpatient beds. The survey consisted of a brief scripted portrayal of 6 hypothetical patients who may be admitted to a hospital's general floor, ICU, or an intermediate care unit (IMCU). The scenarios included severe asthma, bronchiolitis, croup, diabetic ketoacidosis, and patients dependent on home ventilation via noninvasive interface or tracheostomy. The hospital bed coordinator or emergency department charge nurse was asked where each hypothetical patient would be admitted in their hospital. RESULTS: A total192 hospitals met inclusion criteria and 164 hospitals (85%) responded. For all of the scenarios, most of the institutions triaged them to the PICU. Twenty-eight (17%) of the responding institutions triaged at least 1 of the patient scenarios to an IMCU. The presence of an IMCU decreased triage to the ICU for all scenarios when comparing hospitals with and without an IMCU (P < .001). CONCLUSIONS: Inpatient triage practices among pediatric hospitals vary widely for patients who require intense nursing or frequent monitoring due to specific acute illnesses or respiratory technologies. Institutions that have an IMCU available are less likely to send these patients to the ICU.

Objective The number of pediatric Global Health (GH) tracks has more than doubled in less than 10 years. The goal of this study was to describe the characteristics of the pediatric GH tracks to identify commonalities and differences in track structure, funding, and education. In addition, we also identified demographic, institutional, and residency-related factors that were significantly associated with educational offerings and logistical challenges. Methods A cross-sectional survey was electronically administered to pediatric residency programs with GH tracks. Statistical analyses included frequencies to describe GH track characteristics. Fisher's exact tests were used to identify bivariate associations between track structure and funding with educational offerings and logistical challenges. Results Leaders of 32 pediatric GH tracks (67%) completed the survey. The majority of GH tracks were completed within the 3 years of residency (94%) and identified a GH track director (100%); however, tracks varied in size, enrollment methods, domestic and international partnerships, funding, and evaluations. Dedicated faculty time and GH track budget amounts were associated with more robust infrastructure pertaining to resident international electives, including funding and mentorship. Many tracks did not meet American Academy of Pediatrics recommended standards for clinical international rotations. Conclusions Despite the presence of multiple similarities among pediatric GH tracks, there are large variations in track structure, education, and funding. The results from this study support the proposal of a formal definition and minimum standards for a GH track, which may provide a framework for quality, consistency, and comparison of GH tracks.

Although there has been rapid growth in global health educational experiences over the last two decades, the flow of learners remains overwhelmingly one directional; providers from high-resourced settings travel to limited-resourced environments to participate in clinical care, education, and/or research. Increasingly, there has been a call to promote parity in partnerships, including the development of bidirectional exchanges, where trainees from each institution travel to the partner's setting to learn from and teach each other. As global health educators and steering committee members of the Association of Pediatric Program Directors Global Health Pediatric Education Group, we endorse the belief that we must move away from merely sending learners to international partner sites and instead become true global health partners offering equitable educational experiences. In this article, we summarize the benefits, review common challenges, and highlight solutions to hosting and providing meaningful global health experiences for learners from limited-resourced partner institutions to academic health centers in the United States.

Background Investments in faculty exchanges to build physician workforce capacity are increasing. Little attention has been paid to the expectations of host institution faculty and trainees. This prospective qualitative research study explored faculty and resident perspectives about guest faculty in paediatric departments in East Africa, asking (1) What are the benefits and challenges of hosting guest faculty, (2) What factors influence the effectiveness of faculty visits and (3) How do host institutions prepare for faculty visits? Methods We recruited 36 faculty members and residents from among four paediatric departments in East Africa to participate in semistructured interviews which were audio recorded and transcribed. Data were qualitatively analysed using principles of open coding and thematic analysis. We achieved saturation of themes. Results Benefits of faculty visits varied based on the size and needs of host institutions. Emergent themes included the importance of guest faculty time commitment, and mutual preparation to ensure that visit goals and scheduling met host needs. We documented conflicts that developed around guest emotional responses and ethical approaches to clinical resource limitations, which some hosts tried to prepare for and mitigate. Imbalance in resources led to power differentials; some hosts sought partnerships to re-establish control over the process of having guests. Conclusions We identified that guest faculty can assist paediatric institutions in building capacity; however, effective visits require: (1) mutually agreed on goals with appropriate scheduling, visit length and commitment to ensure that the visits meet the host9s needs, (2) careful selection and preparation of guest faculty to meet the host9s goals, (3) emotional preparation by prospective guests along with host orientation to clinical work in the host9s setting and (4) attention to funding sources for the visit and mitigation of resulting power differentials.

Background: Interest is growing in strengthening postgraduate medical education in low-income countries. The purpose of this study was to understand how postgraduate pediatric training programs are developed in countries with no or few pediatric training opportunities. The authors sought to describe and compare a purposive sample of such new programs, and identify challenges and solutions for successful program establishment and sustainability. Methods: The authors queried national pediatric email lists and the Accreditation Council for Graduate Medical Education (ACGME) accredited pediatric residency programs in the United States to identify four pediatric training programs that met study criteria. All four programs responded to a questionnaire with quantitative and qualitative components. Qualitative responses were analyzed for themes. Results: Four centers - in Kenya, Laos, Eritrea and Cambodia - met study criteria. Reported challenges to program development and sustainability centered on faculty development and retention, training in pediatric subspecialties, creating pipelines for applicants and graduates, and funding. These themes were used to develop a logic model, which provides a framework for planning, implementing and evaluating new postgraduate general pediatric training program in low-income countries. Discussion: This study compares four postgraduate general pediatric training programs that were recently established and now continue to graduate pediatric residents in low-income countries. Lessons derived from these programs may help guide practice and research for other centers seeking to establish similar programs.

A concept is proposed to increase the matrix cracking stress of some brittle-matrix composites by taking advantage of the redistribution of internal stresses that occurs when a composite with phases that have dissimilar creep behavior is subjected to thermomechanical loading. The concept is elaborated through the stress analysis of a model unidirectional composite with constituents that exhibit linear viscoelastic behavior. It is shown that if a composite with a matrix that is less creep resistant than the fibers is subjected to a treatment involving both thermal and mechanical loading (e.g. creep test), stresses can be transferred from the matrix to the fibers, resulting in the stress–relaxation of the matrix. Furthermore, it is also shown that by the elastic recovery of the fibers, the matrix can be subjected to large compressive residual stresses at the end of the treatment. The conditions for the viability of this concept and the implications of fiber overloading and potential loss of composite-like behavior are discussed.