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International audience; OBJECTIVES: The overall death toll from COVID-19 in Africa is reported to be low but there is little individual-level evidence on the severity of the disease. This study examined the clinical spectrum and outcome of patients monitored in COVID-19 care centres (CCCs) in two West-African countries. METHODS: Burkina Faso and Guinea set up referral CCCs to hospitalise all symptomatic SARS-CoV-2 carriers, regardless of the severity of their symptoms. Data collected from hospitalised patients by November 2020 are presented. RESULT: A total of 1,805 patients (64% men, median age 41 years) were admitted with COVID-19. Symptoms lasted for a median of 7 days (IQR 4-11). During hospitalisation, 443 (25%) had a SpO2 < 94% at least once, 237 (13%) received oxygen and 266 (15%) took corticosteroids. Mortality was 5% overall, and 1%, 5% and 14% in patients aged

Background Point-of-care ultrasound (POCUS) is nowadays an essential tool in critical care. Its role seems more important in neonates and children where other monitoring techniques may be unavailable. POCUS Working Group of the European Society of Paediatric and Neonatal Intensive Care (ESPNIC) aimed to provide evidence-based clinical guidelines for the use of POCUS in critically ill neonates and children. Methods Creation of an international Euro-American panel of paediatric and neonatal intensivists expert in POCUS and systematic review of relevant literature. A literature search was performed, and the level of evidence was assessed according to a GRADE method. Recommendations were developed through discussions managed following a Quaker-based consensus technique and evaluating appropriateness using a modified blind RAND/UCLA voting method. AGREE statement was followed to prepare this document. Results Panellists agreed on 39 out of 41 recommendations for the use of cardiac, lung, vascular, cerebral and abdominal POCUS in critically ill neonates and children. Recommendations were mostly (28 out of 39) based on moderate quality of evidence (B and C). Conclusions Evidence-based guidelines for the use of POCUS in critically ill neonates and children are now available. They will be useful to optimise the use of POCUS, training programs and further research, which are urgently needed given the weak quality of evidence available.

Las Guías Internacionales de la Campaña Sobreviviendo a la Sepsis para el Manejo del Shock Séptico y la Disfunción de Órganos Asociada a la Sepsis en Niños, fueron publicadas en 2020 y están desti- nadas a ser utilizadas en todos los lugares que atienden a niños. Sin embargo, los profesionales que atienden a los niños con sepsis en entornos con recursos limitados se enfrentan a una serie de desafíos y perfiles de enfermedad distintos a los que se encuentran en entornos ricos en recursos. Basándonos en nuestra experiencia colectiva en entornos con recursos limitados, nos propusimos reflexionar so- bre las dificultades de aplicar las directrices internacionales. Creemos que hay una necesidad urgente de más evidencia de entornos con recursos limitados en enfoques factibles y eficaces para el trata- miento de la sepsis y el shock séptico que podrían incluirse en las futuras directrices para situaciones y contextos específicos.

Additional file 1. Online supplementary material.

Fluid resuscitation is the recommended management of shock, but increased mortality in febrile African children in the FEAST trial. We hypothesised that fluid bolus-induced deaths in FEAST would be associated with detectable changes in cardiovascular, neurological, or respiratory function, oxygen carrying capacity, and blood biochemistry.We developed composite scores for respiratory, cardiovascular, and neurological function using vital sign data from the FEAST trial, and used them to compare participants from FEAST with those from four other cohorts and to identify differences between the bolus (n=2097) and no bolus (n=1044) groups of FEAST. We calculated the odds of adverse outcome for each ten-unit increase in baseline score using logistic regression for each cohort. Within FEAST participants, we also compared haemoglobin and plasma biochemistry between bolus and non-bolus patients, assessed the effects of these factors along with the vital sign scores on the contribution of bolus to mortality using Cox proportional hazard models, and used Bayesian clustering to identify subgroups that differed in response to bolus. The FEAST trial is registered with ISRCTN, number ISRCTN69856593.Increasing respiratory (odds ratio 1·09, 95% CI 1·07-1·11), neurological (1·26, 1·21-1·31), and cardiovascular scores (1·09, 1·05-1·14) were associated with death in FEAST (all p0·0001), and with adverse outcomes for specific scores in the four other cohorts. In FEAST, fluid bolus increased respiratory and neurological scores and decreased cardiovascular score at 1 h after commencement of the infusion. Fluid bolus recipients had mean 0·33 g/dL (95% CI 0·20-0·46) reduction in haemoglobin concentration after 8 h (p0·0001), and at 24 h had a decrease of 1·41 mEq/L (95% CI 0·76-2·06; p=0·0002) in mean base excess and increase of 1·65 mmol/L (0·47-2·8; p=0·0070) in mean chloride, and a decrease of 0·96 mmol/L (0·45 to 1·47; p=0·0003) in bicarbonate. There were similar effects of fluid bolus in three patient subgroups, identified on the basis of their baseline characteristics. Hyperchloraemic acidosis and respiratory and neurological dysfunction induced by saline or albumin bolus explained the excess mortality due to bolus in Cox survival models.In the resuscitation of febrile children, albumin and saline boluses can cause respiratory and neurological dysfunction, hyperchloraemic acidosis, and reduction in haemoglobin concentration. The findings support the notion that fluid resuscitation with unbuffered electrolyte solutions may cause harm and their use should be cautioned. The effects of lower volumes of buffered solutions should be evaluated further.Medical Research Council, Department for International Development, National Institute for Health Research, Imperial College Biomedical Research Centre.

IntroductionIn low-resource countries, respiratory failure is associated with a high mortality risk among critically ill children. We evaluated the role of bubble continuous positive airway pressure (bCPAP) in the routine care of critically ill children in Lilongwe, Malawi.MethodsWe conducted an observational study between 26 February and 15 April 2014, in an urban paediatric unit with approximately 20 000 admissions/year (in-hospital mortality Results117 children with signs of respiratory failure were included in this study and treated with bCPAP. Median age: 7 months. Malaria rapid diagnostic tests were positive in 25 (21%) cases, 15 (13%) had severe anaemia (Hb < 7.0 g/dL); 55 (47%) children had multiorgan failure (MOF); 22 (19%) children were HIV-infected/exposed. 28 (24%) were severely malnourished. Overall survival was 79/117 (68%); survival was 54/62 (87%) in children with very severe pneumonia (VSPNA) but without MOF. Among the 19 children with VSPNA (single-organ failure (SOF)) and negative HIV tests, all children survived. Survival rates were lower in children with MOF (including shock) (45%) as well as in children with severe malnutrition (36%) and proven HIV infection or exposure (45%).ConclusionDespite the limitations of this study, the good outcome of children with signs of severe respiratory dysfunction (SOF) suggests that it is feasible to use bCPAP in the hospital management of critically ill children in resource-limited settings. The role of bCPAP and other forms of non-invasive ventilatory support as a part of an improved care package for critically ill children with MOF at tertiary and district hospital level in low-resource countries needs further evaluation. Critically ill children with nutritional deficiencies and/or HIV infection/exposure need further study to determine bCPAP efficacy.

INTRODUCTION: worldwide around 30 - 40% of deaths in children occur in neonates with the principal causes of morbidity and mortality being sepsis, birth-asphyxia and prematurity. In 2016, MSF- OCB registered 7,272 exits from 10 neonatal units in low-resource settings with a mortality rate of approximately 13%. Birth-weight was a major factor determining the mortality risk of newborns. In some units, the care of extremely low birth-weight (ELBW) (< 1000 grams) and very low birth-weight (VLBW) (1000 - 1500 grams) newborns with significant morbidities is relatively invasive (e.g. prolonged use of intravenous medications and fluids) and human resource intensive. We suggest that by using a “minimally-invasive approach” in VLBW, appropriate care can be provided, while avoiding harm and using resources efficiently. METHODS: the unique needs of VLBW newborns were considered. In order to recommend a “minimally-invasive approach”, we reviewed literature and considered the capacities of both basic and more advanced emergency obstetric and neonatal care units. RESULTS: this approach can be operationalized by prioritizing interventions such as effective basic newborn resuscitation, early proactive introduction of enteral feeds, limited use of intravenous fluids, simplified antibiotic regimens for certain patient groups, minimal handling and bundling of care, earlier maternal interaction with the infant as well as efficient respiratory support. CONCLUSION: for VLBW infants, minimally-invasive care translated into these clinical interventions could help to improve access to efficient neonatal care by allowing decentralized care in remote settings while leading to decongestion of overcrowded neonatal units. While using resources more efficiently, a less invasive approach to newborn care has the potential to improve the outcome of newborns managed in MSF-settings. In more advanced settings, this approach might also free up resources to focus on interventions with a potentially high impact on survival of VLBW-neonates (e.g. introduction of non-invasive respiratory support). This approach warrants further evaluation.

How was I supposed to know what sepsis was, if my doctor wasn’t thinking about it. Melissa Mead1 William Mead and his family were failed by a health system that ‘lacked understanding of sepsis, particularly in children (Secretary of State for Health)’ (http://http://www.youtube.com/watch?v=Qmw7YfxEIUU). Postmortem review identified a number of ‘missed opportunities’ for an earlier diagnosis and escalation in William's care (http:s//www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/03/root-cause-analysis-wm-report.pdf), and each recommendation proposed by an expert panel, which included William's mother, has been acted on. We now have a National Health Service (NHS) system-wide action plan for improving outcomes in patients with sepsis (https://www.england.nhs.uk/wp-content/uploads/2015/08/Sepsis-Action-Plan-23.12.15-v1.pdf), and tools for medical professionals and parents looking after children (http://sepsistrust.org/wp-content/uploads/2015/08/sepsis-toolkit-FINAL-09151.pdf). In December 2015, the National Medical Director of NHS-England wrote that sepsis care was ‘about ensuring that professionals are supported and equipped to be aware of sepsis, ensuring that they have access to evidence based guidelines, and that they are trained in identifying and treating sepsis promptly.’ (Notwithstanding, of course, the need for a clinical approach that adheres to good antibiotic stewardship.) Now, de Vos-Kerkhof et al 2 provide new information that helps with the recognition and identification aspect of this sepsis strategy—but, first, let us consider the context of two recent articles. Sepsis is a global health problem. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) 3 updated previous definitions used in adults and presented a novel approach to using clinical criteria for identifying patients with greater …

In low resource-countries, the mortality of critically-ill children remains high. Severe pneumonia remains one of the leading causes of death. Malaria and intercurrent bacteraemia adversly affects survival in this setting. Low cost bubble continuous positive airway pressure (bCPAP) set-ups are used in some reference centres in sub-Saharan Africa. More evidence for use beyond the neonatal period is needed. We evaluated the role of bCPAP for the care of critically-ill children in Lilongwe, Malawi. This observational study was conducted between 26 February-15 April 2014, in a busy, urban paediatric unit with >20,000 admissions/year (in-hospital mortality ~ 3%). Modified oxygen concentrators or oxygen cylinders provided humidified bCPAP air/oxygen flow. The inclusion criteria was a convenience sample of non-neonates initiated on bCPAP at the discretion of a clinician. BCPAP failure was defined as; death during bCPAP treatment, within 48 h of bCPAP weaning, or escalation to intubation. Ethical approval was from the Malawi National Health-Sciences Research-Committee. 116 children with symptoms of WHO defined very severe pneumonia (VSPNA) were included. Median age: 8 months. Median duration of bCPAP treatment: 2.5 days. Malaria rapid-tests were positive in 36 (31%) cases. 34 (29%) had severe anaemia (Hb 1 organ-failure (MOF). 23 (20%) children were HIV-positive/exposed. 24 (21%) were malnourished. The over-all survival was 74/116 (64%). 33/34 (97%) with signs of uncomplicated VSPNA survived and HIV infection/exposure did appear to affect survival in this group. Treatment failure rates rose with the presence of respiratory depression, MOF or signs of shock (delayed capillary refill time etc.) The higher survival rates among children with uncomplicated VSPNA indicates that bCPAP could be used in resource-limited, malaria-endemic settings with a high HIV prevalence. This is important to explore, as Malawi has been reported as doing well to reduce under 5 mortality. This success has been attributed to following and implementing new evidence based interventions and policies. The time may have come when critical care skills and technologies from developed settings can be used to benefit those suffering the inordinate burden of disease in the developing world.

Mortality from severe malaria remains unacceptably high in sub-Saharan Africa. Several markers of cardiovascular compromise and metabolic acidosis correlate with mortality. The role of cardiac dysfunction in the pathogenesis of severe childhood malaria remains unknown.We examined 30 children admitted with severe malaria by using portable echocardiography to assess their cardiac function and hemodynamic status on admission (day 0), day 1, and discharge. We compared hemodynamic parameters in two study groups: children presenting with metabolic acidosis (base deficit8) and children without acidosis.High-dependency unit, Kilifi District Hospital, Kenya.Acidotic patients received fluid resuscitation with either dextran 70 or starch at admission.Several markers of hemodynamic compromise were noted on admission, including severe tachycardia, low stroke volume index, and high inferior vena cava collapsibility index, which improved with subsequent readings. Overall, cardiac function assessed by ejection fraction (63.1% +/- 5.2% vs. 71.9% +/- 2.8%; p.001) and left myocardial performance index (0.32 +/- 0.16 vs. 0.25 +/- 0.08; p = .03) was mildly abnormal on admission compared with discharge. Acidotic patients had worse hemodynamic indicators, with a significantly higher inferior vena cava collapsibility index on day 0 than nonacidotic patients (52.1 +/- 21 .9 vs. 37.7 +/- 15.4; p = .03), plus lower stroke volume index and worse cardiac function with higher left myocardial performance index (0.38 +/- 0.18 vs. 0.26 +/- 0.11; p = .05). Stroke volume index increased after first fluid bolus in 80% of children.Children with severe malaria and metabolic acidosis have evidence of hypovolemia and evidence of cardiac dysfunction.

The Ministry of Health, Malawi, for its full support and collaboration during the development and implementation of this programme, including providing salaries for MOH staff during training. Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH for scholarships for BSc for CO PCH 2013–2014 intake and the salary of a paediatrician to provide training to this cadre. University of St Andrews Global Health Implementation programme for funding BSc PCH 2013–2017. University of Edinburgh for funding BSc PCH 2013–2016. The Scottish Government for funding the virtual learning environment for this cadre. Nchima Trust for funding BSc PCH 2014 intake. ELMA Philanthropies for funding MMED scholarships for specialist paediatricians. ELMA Philanthropies for funding BSc 2015–2018 intake, funding for supervision and mentoring visits Background Eighty per cent of Malawi’s 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health. Presentation of the hypothesis Managed clinical networks have been found to improve equity of care in rural districts and to ensure that the correct care is provided as close to home as possible. A network for paediatric care in Malawi with mentoring of non-physician clinicians based in a district hospital by paediatricians based at the central hospitals will establish and sustain clinical referral pathways in both directions. Ultimately, the plan envisages four managed paediatric clinical networks, each radiating from one of Malawi’s four central hospitals and covering the entire country. This model of task sharing within four hub-and-spoke networks may facilitate wider dissemination of scarce expertise and improve child healthcare in Malawi close to the child’s home. Testing the hypothesis Funding has been secured to train sufficient personnel to staff all central and district hospitals in Malawi with teams of paediatric specialists in the central hospitals and specialist non-physician clinicians in each government district hospital. The hypothesis will be tested using a natural experiment model. Data routinely collected by the Ministry of Health will be corroborated at the district. This will include case fatality rates for common childhood illness, perinatal mortality and process indicators. Data from different districts will be compared at baseline and annually until 2020 as the specialists of both cadres take up posts. Implications of the hypothesis If a managed clinical network improves child healthcare in Malawi, it may be a potential model for the other countries in sub-Saharan Africa with similar cadres in their healthcare system and face similar challenges in terms of scarcity of specialists. Publisher PDF