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Children in resource-limited settings (RLS) bear a disproportionate burden of mortality; in 2019, 80% of global child deaths were in RLS. Most acute, life-threatening pediatric illnesses can be managed with basic critical care. However, it is unclear how best to deploy existing resources and select interventions for implementation in the absence of data on pediatric acute critical illness (P-ACI) and associated hospital mortality in RLS. This work aimed to estimate the proportion of children with P-ACI and to determine the common causes of pediatric hospital mortality in RLS hospitals. We performed a systematic review and meta-analysis of observational studies from low- and middle-income countries (RLS proxy) to estimate pediatric cause-specific mortality using random-effects models and analyzed differences by region. We also conducted a point prevalence study of acutely ill or injured children seeking care at RLS hospitals and measured the proportion of children with P-ACI. We summarized site- and population-level data by sociodemographic index (SDI) and P-ACI status and tested for an association between SDI and P-ACI with logistic regression modelling. The proportion of P-ACI was 6-29% and hospital mortality was 0-6%, depending on SDI and region, with the highest estimates from the lowest SDI category. P-ACI and mortality were most frequently associated with infectious diseases. A coordinated global effort is needed to increase high-quality critical care services in RLS hospitals to prevent hospital mortality and care for children with life-threatening conditions.

Iodine intake in Haiti has increased in recent years thanks to the “Bon Sel” social enterprise approach to salt fortification and distribution by the market segment. However, it was uncertain whether this salt reached remote communities. This cross-sectional study aimed to assess the iodine status of school-age children (SAC) and women of reproductive age (WRA) in a remote region of the Central Plateau. A total of 400 children (9–13 years) and 322 women (18–44 years) were recruited through schools and churches, respectively. Urinary iodine (UIC) and urinary creatinine (UCC) concentrations were measured in spot samples, and thyroglobulin (Tg) on dried blood spots. Their iodine intake was estimated, and dietary information collected. The median (IQR) UIC in SAC was 130 µg/L (79–204, n = 399), and in WRA, 115 µg/L (73–173, n = 322). The median (IQR) Tg in SAC was 19.7 µg/L (14.0–27.6, n = 370), and in WRA, 12.2 µg/L (7.9–19.0, n = 183); 10% of SAC had Tg > 40 µg/L. Estimated iodine intake was 77 µg/day and 202 µg/day in SAC and WRA, respectively. Iodized table salt was rarely consumed, though bouillon was used daily; this is hypothesized to be a major contributor to dietary iodine intake. Iodine intake in this remote region seems to have improved considerably since the 2018 national survey, though SAC remain at risk. These results point to the potential effectiveness of using social business principles to deliver humanitarian solutions., Nutrients, 15 (5), ISSN:2072-6643

BackgroundGlobally, injuries cause >5 million deaths annually and children and young people are particularly vulnerable. Injuries are the leading cause of death in people aged 5–24 years and a leading cause of disability. In most low-income and middle-income countries where the majority of global child injury burden occurs, systems for routinely collecting injury data are limited.MethodsA new model of injury surveillance for use in emergency departments in Nepal was designed and piloted. Data from patients presenting with injuries were collected prospectively over 12 months and used to describe the epidemiology of paediatric injury presentations.ResultsThe total number of children ConclusionInjuries affecting children in Nepal represent a significant burden. The data on injuries observed from falls, road traffic injuries and injuries related to animals suggest potential areas for injury prevention. This is the biggest prospective injury surveillance study in Nepal in recent years and supports the case for using injury surveillance to monitor child morbidity and mortality through improved data.

Background & aims: Severe Acute Malnutrition (SAM) in children is determined using anthropometry. However, bio-electrical impedance (BI) analysis could improve the estimation of altered body composition linked to edema and/or loss of lean body mass in children with SAM. We aimed to assess: 1) the changes in BI parameters during clinical stabilization and 2) whether BI parameters add prognostic value for clinical outcome beyond the use of anthropometry. Methods: This prospective observational study enrolled children, aged 6–60 months, that were admitted at Queen Elizabeth Central Hospital in Blantyre, Malawi, for complicated SAM (i.e., having either severe wasting or edematous SAM with a complicating illness). Height, weight, mid-upper arm circumference (MUAC), and BI were measured on admission and after clinical stabilization. BI measures were derived from height-adjusted indices of resistance (R/H), reactance (Xc/H), and phase angle (PA) and considered to reflect body fluids and soft tissue in BI vector analysis (BIVA). Results: We studied 183 children with SAM (55% edematous; age 23.0 ± 12.0 months; 54% male) and 42 community participants (age 20.1 ± 12.3 months; male 62%). Compared to community participants, the BIVA of children with edematous SAM were short with low PA and positioned low on the hydration axis which reflects severe fluid retention. In contrast, children with severe wasting had elongated vectors with a PA that was higher than children with edematous SAM but lower than community participants. Their BIVA position fell within the top right quadrant linked to leanness and dehydration. BIVA from severely wasted and edematous SAM patients differed between groups and from community children both at admission and after stabilization (p < 0.001). Vector position shifted during treatment only in children with edematous SAM (p < 0.001) and showed a upward translation suggestive of fluid loss. While PA was lower in children with SAM, PA did not contribute more than anthropometry alone towards explaining mortality, length of stay, or time-to-discharge or time-to-mortality. The variability and heterogeneity in BI measures was high and their overall added predictive value for prognosis of individual children was low. Conclusions: BIVA did not add prognostic value over using anthropometry alone to predict clinical outcome. Several implementation challenges need to be optimized. Thus, in low-resource settings, the routine use of BI in the management of pediatric malnutrition is questionable without improved implementation.

ObjectiveCompare paediatric COVID-19 disease characteristics, management and outcomes according to World Bank country income level and disease severity.DesignSystematic review and meta-analysis.SettingBetween 1 December 2019 and 8 January 2021, 3350 articles were identified. Two reviewers conducted study screening, data abstraction and quality assessment independently and in duplicate. Observational studies describing laboratory-confirmed paediatric (0–19 years old) COVID-19 were considered for inclusion.Main outcomes and measuresThe pooled proportions of clinical findings, treatment and outcomes were compared according to World Bank country income level and reported disease severity.Results129 studies were included from 31 countries comprising 10 251 children of which 57.4% were hospitalised. Mean age was 7.0 years (SD 3.6), and 27.1% had a comorbidity. Fever (63.3%) and cough (33.7%) were common. Of 3670 cases, 44.1% had radiographic abnormalities. The majority of cases recovered (88.9%); however, 96 hospitalised children died. Compared with high-income countries, in low-income and middle-income countries, a lower proportion of cases were admitted to intensive care units (ICUs) (9.9% vs 26.0%) yet pooled proportion of deaths among hospitalised children was higher (relative risk 2.14, 95% CI 1.43 to 3.20). Children with severe disease received antimicrobials, inotropes and anti-inflammatory agents more frequently than those with non-severe disease. Subgroup analyses showed that a higher proportion of children with multisystem inflammatory syndrome (MIS-C) were admitted to ICU (47.1% vs 22.9%) and a higher proportion of hospitalised children with MIS-C died (4.8% vs 3.6%) compared with the overall sample.ConclusionPaediatric COVID-19 has a favourable prognosis. Further severe disease characterisation in children is needed globally.

BackgroundNeonates are at major risk of sepsis, but data on neonatal sepsis incidence are scarce. We aimed to assess the incidence and mortality of neonatal sepsis worldwide.MethodsWe performed a systematic review and meta-analysis. 13 databases were searched for the period January 1979–May 2019, updating the search of a previous systematic review and extending it in order to increase data inputs from low-income and middle-income countries (LMICs). We included studies on the population-level neonatal sepsis incidence that used a clinical sepsis definition, such as the 2005 consensus definition, or relevant ICD codes. We performed a random-effects meta-analysis on neonatal sepsis incidence and mortality, stratified according to sepsis onset, birth weight, prematurity, study setting, WHO region and World Bank income level.ResultsThe search yielded 4737 publications, of which 26 were included. They accounted for 2 797 879 live births and 29 608 sepsis cases in 14 countries, most of which were middle-income countries. Random-effects estimator for neonatal sepsis incidence in the overall time frame was 2824 (95% CI 1892 to 4194) cases per 100 000 live births, of which an estimated 17.6% 9 (95% CI 10.3% to 28.6%) died. In the last decade (2009–2018), the incidence was 3930 (95% CI 1937 to 7812) per 100 000 live births based on four studies from LMICs. In the overall time frame, estimated incidence and mortality was higher in early-onset than late-onset neonatal sepsis cases. There was substantial between-study heterogeneity in all analyses. Studies were at moderate to high risk of bias.ConclusionNeonatal sepsis is common and often fatal. Its incidence remains unknown in most countries and existing studies show marked heterogeneity, indicating the need to increase the number of epidemiological studies, harmonise neonatal sepsis definitions and improve the quality of research in this field. This can help to design and implement targeted interventions, which are urgently needed to reduce the high incidence of neonatal sepsis worldwide.

Objective To explore stressors and support system for families with a neonate admitted with a systemic infection. Design Qualitative study using in-depth interviews (IDIs), based on principles of grounded theory. Setting A busy level III neonatal unit of a tertiary care teaching hospital in coastal Karnataka, India, between May 2018 and January 2019. Participants Parents and accompanying attendants of neonates admitted to the neonatal unit with one or more systemic infections. Methods Using purposive sampling, semi-structured IDIs were audio recorded, transcribed verbatim and a thematic analysis was performed. Results Thirty-eight participants were interviewed, lasting between 30 and 59 min. Babies’ hospitalisation with sepsis was an unprecedented, sudden and overwhelming event. Stressors related to uncertainties due to the information gap inherent to the nature of illness, cultural rituals, financial constraints, barriers to bonding and others. Parents reported experiencing insomnia, gastric disturbances and fatigue. Support (emotional and/or financial) was sought from families and friends, peers, staff and religion. Availability and preference of emotional support system differed for mothers and fathers. In our context, families, peers and religion were of particular importance for reinforcing the available support system. Participant responses were shaped by clinical, cultural, financial, religious and health service contexts. Conclusion Designing a family-centred care in our context needs consideration of stressors that extend beyond the immediate neonatal intensive care unit environment and interactions. Understanding the influence of the nature of illness, financial, familial and cultural contexts helps identify the families who are particularly vulnerable to stress., In the S Indian context, support for parents whose child is admitted to a neonatal unit with sepsis needs to go beyond the NICU and include, extended family, cultural and financial issues as well as NICU practices.

The first years of life are a sensitive period of rapid neural and immune system development vulnerable to the impact of adverse experiences. Several studies support inflammation as a consequence of various adversities and an exposure negatively associated with developmental outcomes. The mechanism by which systemic inflammation may affect brain development and later cognitive outcomes remains unclear. In this longitudinal cohort study, we examine the associations between recurrent systemic inflammation, defined as C-reactive protein elevation on ≥ 2 of 4 measurements across the first year of life, electroencephalography (EEG) functional connectivity (FC) at 36 months, and composite cognitive outcomes at 3, 4, and 5 years among 122 children living in a limited-resource setting in Dhaka, Bangladesh. Recurrent systemic inflammation during the first year of life is significantly negatively associated with cognitive outcomes at 3, 4, and 5 years, after accounting for stunting and family care indicators (a measure of stimulation in the home environment). Recurrent systemic inflammation is significantly positively associated with parietal-occipital FC in the Beta band at 36 months, which in turn is significantly negatively associated with composite cognitive scores at 3 and 4 years. However, FC does not mediate the relationship between recurrent systemic inflammation and cognitive outcomes.

ObjectivePrognostic models aid clinical decision making and evaluation of hospital performance. Existing neonatal prognostic models typically use physiological measures that are often not available, such as pulse oximetry values, in routine practice in low-resource settings. We aimed to develop and validate two novel models to predict all cause in-hospital mortality following neonatal unit admission in a low-resource, high-mortality setting.Study design and settingWe used basic, routine clinical data recorded by duty clinicians at the time of admission to derive (n=5427) and validate (n=1627) two novel models to predict in-hospital mortality. The Neonatal Essential Treatment Score (NETS) included treatments prescribed at the time of admission while the Score for Essential Neonatal Symptoms and Signs (SENSS) used basic clinical signs. Logistic regression was used, and performance was evaluated using discrimination and calibration.ResultsAt derivation, c-statistic (discrimination) for NETS was 0.92 (95% CI 0.90 to 0.93) and that for SENSS was 0.91 (95% CI 0.89 to 0.93). At external (temporal) validation, NETS had a c-statistic of 0.89 (95% CI 0.86 to 0.92) and SENSS 0.89 (95% CI 0.84 to 0.93). The calibration intercept for NETS was −0.72 (95% CI −0.96 to −0.49) and that for SENSS was −0.33 (95% CI −0.56 to −0.11).ConclusionUsing routine neonatal data in a low-resource setting, we found that it is possible to predict in-hospital mortality using either treatments or signs and symptoms. Further validation of these models may support their use in treatment decisions and for case-mix adjustment to help understand performance variation across hospitals.

BackgroundPneumonia is the largest cause of child deaths in low-income countries. Lack of availability of oxygen in small rural hospitals results in avoidable deaths and unnecessary and unsafe referrals.MethodWe evaluated a programme for improving reliable oxygen therapy using oxygen concentrators, pulse oximeters and sustainable solar power in 38 remote health facilities in nine provinces in Papua New Guinea. The programme included a quality improvement approach with training, identification of gaps, problem solving and corrective measures. Admissions and deaths from pneumonia and overall paediatric admissions, deaths and referrals were recorded using routine health information data for 2–4 years prior to the intervention and 2–4 years after. Using Poisson regression we calculated incidence rates (IRs) preintervention and postintervention, and incidence rate ratios (IRR).ResultsThere were 18 933 pneumonia admissions and 530 pneumonia deaths. Pneumonia admission numbers were significantly lower in the postintervention era than in the preintervention era. The IRs for pneumonia deaths preintervention and postintervention were 2.83 (1.98–4.06) and 1.17 (0.48–1.86) per 100 pneumonia admissions: the IRR for pneumonia deaths was 0.41 (0.24–0.71, pConclusionsSolar-powered oxygen systems supported by continuous quality improvement can be achieved at large scale in rural and remote hospitals and health care facilities, and was associated with reduced child deaths and reduced referrals. Variability of effectiveness in different contexts calls for strengthening of quality improvement in rural health facilities.Trial registration numberACTRN12616001469404.

ObjectiveWe aimed to explore the views of Malaysian children with asthma and their parents to enhance understanding of early influences on development of self-management skills.DesignThis is a qualitative study conducted among children with asthma and their parents. We used purposive sampling and conducted focus groups and interviews using a semi-structured topic guide in the participants’ preferred language. All interviews were audio-recorded, transcribed verbatim, entered into NVivo and analysed using a grounded theory approach.SettingsWe identified children aged 7–12 years with parent-reported, physician-diagnosed asthma from seven suburban primary schools in Malaysia. Focus groups and interviews were conducted either at schools or a health centre.ResultsNinety-nine participants (46 caregivers, 53 children) contributed to 24 focus groups and 6 individual interviews. Children mirrored their parents’ management of asthma but, in parallel, learnt and gained confidence to independently self-manage asthma from their own experiences and self-experimentation. Increasing independence was more apparent in children aged 10 years and above. Cultural norms and beliefs influenced children’s independence to self-manage asthma either directly or indirectly through their social network. External influences, for example, support from school and healthcare, also played a role in the transition.ConclusionChildren learnt the skills to self-manage asthma as early as 7 years old with growing independence from the age of 10 years. Healthcare professionals should use child-centred approach and involve schools to facilitate asthma self-management and support a smooth transition to independent self-management.Trial registration numberMalaysian National Medical Research Register (NMRR-15-1242-26898).

BackgroundThe WHO reports excessive rates of ill-defined neurological diagnoses and ineffective and potentially harmful drug treatments in children in the Commonwealth of Independent States (CIS). Collectively termed perinatal encephalopathy and the syndrome of intracranial hypertension (PE-SIH), these diagnoses are important contributors to perceived childhood morbidity and disability in the CIS. A systematic compilation of information on PE-SIH is lacking.MethodsWe systematically reviewed publications between 1970 and 2020 on PE-SIH in Azerbaijani, English, Russian and Ukrainian languages and summarised information on PE-SIH.ResultsWe identified 30 publications (70% in Russian) published 1976–2017. The diagnosis of PE-SIH was either based on unreported criteria (67% of reports), non-specific clinical features of typically developing children or those with common developmental disorders (20% of reports) or cranial ultrasound (13% of reports). The reported proportion of children with PE-SIH in the study samples ranged from 31% to 99%. There were few published studies on reassessments of children diagnosed with PE-SIH, and these did not confirm neurological disease in the majority of children. Treatments included multiple unlicenced drugs without established effectiveness and with potential unwanted effects.ConclusionThis review suggests that PE-SIH is a medical diagnostic label that is used in numerous children without substantive associated disease. The diagnosis and treatment of PE-SIH is a multidimensional, iatrogenic, clinical and public health problem in the CIS. With increasing use of evidence-based medicine guidelines in the region, it is hoped that PE-SIH will gradually disappear, but actions to accelerate this change are nevertheless needed.

ObjectiveTo investigate foot length (FL), chest circumference (CHC) and mid-upper arm circumference (MUAC) as predictors of low birth weight (LBW) or prematurity, and to describe the agreement between the gestational age (GA) assessments ascertained by the New Ballard Score (NBS) and the Eregie model.MethodsA hospital-based cross-sectional study with community follow-up in a subset was conducted in Jimma University Medical Center, Ethiopia. GA (NBS and Eregie model), weight, FL, CHC and MUAC were measured at birth. Anthropometrics were repeated at 5 days of age.ResultsThe optimal cut-offs indicative of LBW were ≤7.7 cm for FL; ≤31.2 cm for CHC and ≤9.8 cm for MUAC. CHC, MUAC and FL identified LBW with sensitivities (95% CI) of 91.6 (86.9 to 95), 83.7 (77.8 to 88.5) and 84.2 (78.4 to 88.9), and specificities (95% CI) of 85.4 (83.3 to 87.4), 90.2 (88.4 to 91.9) and 73.9 (71.3 to 76.4), respectively. CHC, MUAC and FL identified prematurity with sensitivities of 83.8 (76.7 to 89.4), 83.1 (75.9 to 88.9) and 81.7 (74.3 to 87.7), and specificities of 81.1 (78.9 to 83.3), 63.4 (60.7 to 66.1) and 77.0 (74.6 to 79.3), respectively. The cut-offs identified have comparable diagnostic ability for LBW and prematurity when measurements are repeated on day 5 of age. The GA assessment by the NBS and the Eregie model gave similar results, with the mean difference of 1.2 weeks.ConclusionCHC, MUAC and FL taken on day 1 and 5 after birth could be used as diagnostic tools for LBW or prematurity. The Eregie model for GA estimation gives similar results to the NBS.

The COVID-19 pandemic curve in Africa has lagged behind that of Europe. The first case of SARS-CoV-2 in Malawi was confirmed on 2 April.1 Malawi closed schools and airports, but no ‘lockdown’ was enforced in recognition of the risk to a population vulnerable to economic and health service disruption.2 Although overall ascertainment was low, detection of cases nationwide confirmed community transmission by July. Nonetheless, the number of acute cases presenting to hospital remained less than expected. The current total number of confirmed COVID-19 cases nationwide is just over 60001 with Blantyre district contributing one-third of the nationwide total.3 Queen Elizabeth Central Hospital (QECH) in Blantyre is the tertiary referral hospital for the Southern Region of Malawi. The pandemic heightened existing challenges related to limited human and material resources. Public fear and healthcare worker (HCW) sit-ins associated with concerns around inadequate personal protective equipment (PPE) disrupted services and contributed to delayed patient presentation. We established a multidisciplinary COVID-19 task force to work with hospital, district and national leaders in the coordination of activities aimed at mitigating the direct and indirect risks of the COVID-19 pandemic on staff and paediatric patients. We now reflect and share our initial lessons in pandemic preparedness in the Department of Paediatrics at QECH. In the early months of the pandemic, there was mounting evidence that the risk of nosocomial transmission and occupational exposure was high.4 5 In response, the Ministry of Health of Malawi developed COVID-19 treatment centres separate from central hospitals. This policy was challenging for paediatrics as the WHO clinical case definition used for isolation overlaps with the majority of in-patient paediatric diagnoses. Limited diagnostics led to a risk of inappropriate isolation, unnecessary exposure of high-risk children and guardians to COVID-19 and a reduced level of specialty care for …

Preventable neonatal deaths due to prematurity, perinatal events, and infections are the leading causes of under-five mortality. The vast majority of these deaths are in resource-limited areas. Deaths due to infection have been associated with lack of access to clean water, overcrowded nurseries, and improper disinfection (reprocessing) of equipment, including vital resuscitation equipment. Reprocessing has recently come to heightened attention, with the COVID-19 pandemic bringing this issue to the forefront across all economic levels; however, it is particularly challenging in low-resource settings. In 2015, Eslami et al. published a letter to the editor in Resuscitation, highlighting concerns about the disinfection of equipment being used to resuscitate newborns in Kenya. To address the issue of improper disinfection, the global health nongovernment organization PATH gathered a group of experts and, due to lack of best-practice evidence, published guidelines with recommendations for reprocessing of neonatal resuscitation equipment in low-resource areas. The guidelines follow the gold-standard principle of high-level disinfection; however, there is ongoing concern that the complexity of the guideline would make feasibility and sustainability difficult in the settings for which it was designed. Observations from hospitals in Kenya and Malawi reinforce this concern. The purpose of this review is to discuss why proper disinfection of equipment is important, why this is challenging in low-resource settings, and suggestions for solutions to move forward.

Prenatal viral infection can lead to a spectrum of neurodevelopmental disabilities or fetal demise. These can include microencephaly, global developmental delay, intellectual disability, refractory epilepsy, deafness, retinal defects, and cortical-visual impairment. Each of these clinical conditions can occur on a semi-quantitative to continuous spectrum, from mild to severe disease, and often as a collective of phenotypes. Such serious outcomes result from viruses’ overlapping neuropathology and hosts’ common neuronal and gene regulatory response to infections. The etiology of variability in clinical outcomes is not yet clear, but it may be related to viral, host, vector, and/or environmental risk and protective factors that likely interact in multiple ways. In this perspective of the literature, we work toward understanding the causes of phenotypic variability after prenatal viral infections by highlighting key aspects of the viral lifecycle that can affect human disease, with special attention to the 2015 Zika pandemic. Therefore, this work offers important insights into how viral infections and environmental teratogens affect the prenatal brain, toward our ultimate goal of preventing neurodevelopmental disabilities.

ObjectiveTo determine whether Rojiroti microfinance, for poor Indian women, improves child nutrition.DesignCluster randomised trial.SettingTolas (village communities) in Bihar State.ParticipantsWomen and children under 5 years.InterventionsWith Rojiroti microfinance, women form self-help groups and save their money to provide loans to group members. After 6 months, they receive larger external loans. Tolas were randomised to receive Rojiroti immediately or after 18 months.Outcome measuresThe primary analysis compared the mean weight for height Z score (WHZ) of children under 5 years in the intervention versus control tolas who attended for weight and height measurement 18 months after randomisation. Secondary outcomes were weight for age Z score (WAZ), height for age Z score, mid-upper arm circumference (MUAC), wasting, underweight and stunting.ResultsWe randomised 28 tolas to each arm and collected data from 2469 children (1560 mothers) at baseline and 2064 children (1326 mothers) at follow-up. WHZ was calculated for 1718 children at baseline and 1377 (674 intervention and 703 control) at follow-up. At 18 months, mean WHZ was significantly higher for intervention (−1.02) versus controls (−1.37; regression coefficient adjusted for clustering β=0.38, 95% CI 0.16 to 0.61, p=0.001). Significantly fewer children were wasted in the intervention group (122, 18%) versus control (200, 29%; OR=0.46, 95% CI 0.28 to 0.74, p=0.002). Mean WAZ was better in the intervention group (−2.13 vs −2.37; β=0.27, 95% CI 0.11 to 0.43, p=0.001) as was MUAC (13.6 cm vs 13.4 cm; β=0.22, 95% CI 0.03 to 0.40, p=0.02). In an analysis adjusting for baseline nutritional measures (259 intervention children and 300 control), only WAZ and % underweight showed significant differences in favour of the intervention.ConclusionIn marginalised communities in rural India, child nutrition was better in those who received Rojiroti microfinance, compared with controls.Trial registration numberNCT01845545.

The Integrated Management of Childhood Illness (IMCI) was introduced in Central Asia and Europe to address the absence of evidence-based guidelines, antibiotics misuse, polypharmacy and overhospitalisation. This study in 16 countries analyses status, strengths of and barriers to IMCI implementation and investigates how health systems affect the problems IMCI aims to address. 220 key informants were interviewed ranging from 5 to 37 per country (median 12). Data were analysed for arising themes and peer-reviewed. IMCI has not been fully used either as a strategy or as an algorithmic diagnostic and treatment decision tool. Inherent incentives include: economic factors taking precedence over evidence and the best interest of the child in treatment decisions; financing mechanisms and payment schemes incentivising unnecessary or prolonged hospitalisation; prescription of drugs other than IMCI drugs for revenue generation or because believed superior by doctors or parents; parents’ perception that the quality of care at the primary healthcare level is poor; preference for invasive treatment and medicalised care. Despite the long-standing recognition that supportive health systems are a requirement for IMCI implementation, efforts to address health system barriers have been limited. Making healthcare truly universal for children will require a shift towards health systems designed around and for children and away from systems centred on providers’ needs and parents’ expectations. Prerequisites will be sufficient remuneration, sound training, improved health literacy among parents, conducive laws and regulations and reimbursement systems with adequate checks and balances to ensure the best possible care.

ObjectiveTo estimate household cost of illness (COI) for children with severe pneumonia in Bangladesh.DesignAn incidence-based COI study was performed for one episode of childhood severe pneumonia from a household perspective. Face-to-face interviews collected data on socioeconomic, resource use and cost from caregivers. A micro-costing bottom-up approach was applied to calculate medical, non-medical and time costs. Multiple regression analysis was applied to explore the factors associated with COI. Sensitivity analysis explored the robustness of cost parameters.SettingFour urban and rural study sites from two districts in Bangladesh.PatientsChildren aged 2–59 months with severe pneumonia.Results1472 children with severe pneumonia were enrolled between November 2015 and March 2019. The mean age of children was 12 months (SD ±10.2) and 64% were male. The mean household cost per episode was US$147 (95% CI 141.1 to 152.7). Indirect costs were the main cost drivers (65%, US$96). Household costs for the poorest income quintile were lower in absolute terms, but formed a higher proportion of monthly income. COI was significantly higher if treatment was received from urban health facilities compared with rural health facilities (difference US$84.9, 95% CI 73.3 to 96.3). Child age, household income, healthcare facility and hospital length of stay (LoS) were significant predictors of household COI. Costs were most sensitive to hospital LoS and productivity loss.ConclusionsSevere pneumonia in young children is associated with high household economic burden and cost varies significantly across socioeconomic parameters. Management strategies with improved accessibility are needed particularly for the poor to make treatment affordable in order to reduce household economic burden.

In a companion paper, we showed how local hospital leaders could assess systems and identify key safety concerns and targets for system improvement. In the present paper, we consider how these leaders might implement practical, low-cost interventions to improve safety. Our focus is on making immediate safety improvements both to directly improve patient care and as a foundation for advancing care in the longer-term. We describe a ‘portfolio’ approach to safety improvement in four broad categories: prioritising critical processes, such as checking drug doses; strengthening the overall system of care, for example, by introducing multiprofessional handovers; control of known risks, such as only using continuous positive airway pressure when appropriate conditions are met; and enhancing detection and response to hazardous situations, such as introducing brief team meetings to identify and respond to immediate threats and challenges. Local clinical leaders and managers face numerous challenges in delivering safe care but, if given sufficient support, they are nevertheless in a position to bring about major improvements. Skills in improving safety and quality should be recognised as equivalent to any other form of (sub)specialty training and as an essential element of any senior clinical or management role. National professional organisations need to promote appropriate education and provide coaching, mentorship and support to local leaders.

Healthcare systems across the world and especially those in low-resource settings (LRS) are under pressure and one of the first priorities must be to prevent any harm done while trying to deliver care. Health care workers, especially department leaders, need the diagnostic abilities to identify local safety concerns and design actions that benefit their patients. We draw on concepts from the safety sciences that are less well-known than mainstream quality improvement techniques in LRS. We use these to illustrate how to analyse the complex interactions between resources and tools, the organisation of tasks and the norms that may govern behaviours, together with the strengths and vulnerabilities of systems. All interact to influence care and outcomes. To employ these techniques leaders will need to focus on the best attainable standards of care, build trust and shift away from the blame culture that undermines improvement. Health worker education should include development of the technical and relational skills needed to perform these system diagnostic roles. Some safety challenges need leadership from professional associations to provide important resources, peer support and mentorship to sustain safety work.

BackgroundDetection of meningitis is essential to optimise the duration and choice of antimicrobial agents to limit mortality and sequelae. In low and middle-income countries most health facilities lack laboratory capacity and rely on clinical features to empirically treat meningitis.ObjectiveWe conducted a diagnostic validation study to investigate the performance of clinical features (fever, convulsions, irritability, bulging fontanel and temperature ≥39°C) and WHO-recommended signs (drowsiness, lethargy, unconsciousness, convulsions, bulging fontanel, irritability or a high-pitched cry) in discriminating meningitis in young infants.DesignRetrospective cohort study.SettingKilifi County Hospital.PatientsInfants aged Main outcome measureDefinite meningitis defined as positive cerebrospinal fluid (CSF) culture, microscopy or antigen test, or leucocytes ≥0.05 x 10∧9/L.ResultsOf 4809 infants aged ConclusionsDespite a lower prevalence of definite meningitis, the performance of previously identified signs at admission in predicting meningitis was unchanged. Presence of history of fever improves the sensitivity of WHO-recommended signs but loses specificity. Careful evaluation, repeated assessment and capacity for lumbar puncture and CSF microscopy to exclude meningitis in most young infants with potential signs are essential to management in this age group.