Cost of childhood severe pneumonia management in selected public inpatient care facilities in Bangladesh: a provider perspective.

OBJECTIVE: To estimate inpatient care costs of childhood severe pneumonia and its urban-rural cost variation, and to predict cost drivers. DESIGN: The study was nested within a cluster randomised trial of childhood severe pneumonia management. Cost per episode of severe pneumonia was estimated from a healthcare provider perspective for children who received care from public inpatient facilities. A bottom-up micro-costing approach was applied and data collected using structured questionnaire and review of the patient record. Multivariate regression analysis determined cost predictors and sensitivity analysis explored robustness of cost parameters. SETTING: Eight public inpatient care facilities from two districts of Bangladesh covering urban and rural areas. PATIENTS: Children aged 2-59 months with WHO-classified severe pneumonia. RESULTS: Data on 1252 enrolled children were analysed; 795 (64%) were male, 787 (63%) were infants and 59% from urban areas. Average length of stay (LoS) was 4.8 days (SD ±2.5) and mean cost per patient was US$48 (95% CI: US$46, US$49). Mean cost per patient was significantly greater for urban tertiary-level facilities compared with rural primary-secondary facilities (mean difference US$43; 95% CI: US$40, US$45). No cost variation was found relative to age, sex, malnutrition or hypoxaemia. Type of facility was the most important cost predictor. LoS and personnel costs were the most sensitive cost parameters. CONCLUSION: Healthcare provider cost of childhood severe pneumonia was substantial for urban located public health facilities that provided tertiary-level care. Thus, treatment availability at a lower-level facility at a rural location may help to reduce overall treatment costs.

Prevalence and correlates of paediatric guideline non-adherence for initial empirical care in six low and middle-income settings: a hospital-based cross-sectional study.

OBJECTIVES: This study evaluated the prevalence and correlates of guideline non-adherence for common childhood illnesses in low-resource settings. DESIGN AND SETTING: We used secondary cross-sectional data from eight healthcare facilities in six Asian and African countries. PARTICIPANTS: A total of 2796 children aged 2-23 months hospitalised between November 2016 and January 2019 with pneumonia, diarrhoea or severe malnutrition (SM) and without HIV infection were included in this study. PRIMARY OUTCOME MEASURES: We identified children treated with full, partial or non-adherent initial inpatient care according to site-specific standard-of-care guidelines for pneumonia, diarrhoea and SM within the first 24 hours of admission. Correlates of guideline non-adherence were identified using generalised estimating equations. RESULTS: Fully adherent care was delivered to 32% of children admitted with diarrhoea, 34% of children with pneumonia and 28% of children with SM when a strict definition of adherence was applied. Non-adherence to recommendations was most common for oxygen and antibiotics for pneumonia; fluid, zinc and antibiotics for diarrhoea; and vitamin A and zinc for SM. Non-adherence varied by site. Pneumonia guideline non-adherence was more likely among patients with severe disease (OR 1.82; 95% CI 1.38, 2.34) compared with non-severe disease. Diarrhoea guideline non-adherence was more likely among lower asset quintile groups (OR 1.16; 95% CI 1.01, 1.35), older children (OR 1.10; 95% CI 1.06, 1.13) and children presenting with wasting (OR 6.44; 95% CI 4.33, 9.57) compared with those with higher assets, younger age and not wasted. CONCLUSIONS: Non-adherence to paediatric guidelines was common and associated with older age, disease severity, and comorbidities, and lower household economic status. These findings highlight opportunities to improve guidelines by adding clarity to specific recommendations.

Clinical and nutritional correlates of bacterial diarrhoea aetiology in young children: a secondary cross-sectional analysis of the ABCD trial.

OBJECTIVE: The objective was to assess the association between nutritional and clinical characteristics and quantitative PCR (qPCR)-diagnosis of bacterial diarrhoea in a multicentre cohort of children under 2 years of age with moderate to severe diarrhoea (MSD). DESIGN: A secondary cross-sectional analysis of baseline data collected from the AntiBiotics for Children with Diarrhoea trial (NCT03130114). PATIENTS: Children with MSD (defined as >3 loose stools within 24 hours and presenting with at least one of the following: some/severe dehydration, moderate acute malnutrition (MAM) or severe stunting) enrolled in the ABCD trial and collected stool sample. STUDY PERIOD: June 2017-July 2019. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Likely bacterial aetiology of diarrhoea. Secondary outcomes included specific diarrhoea aetiology. RESULTS: A total of 6692 children with MSD had qPCR results available and 28% had likely bacterial diarrhoea aetiology. Compared with children with severe stunting, children with MAM (adjusted OR (aOR) (95% CI) 1.56 (1.18 to 2.08)), some/severe dehydration (aOR (95% CI) 1.66 (1.25 to 2.22)) or both (aOR (95% CI) 2.21 (1.61 to 3.06)), had higher odds of having likely bacterial diarrhoea aetiology. Similar trends were noted for stable toxin-enterotoxigenic Escherichia coli aetiology. Clinical correlates including fever and prolonged duration of diarrhoea were not associated with likely bacterial aetiology; children with more than six stools in the previous 24 hours had higher odds of likely bacterial diarrhoea (aOR (95% CI) 1.20 (1.05 to 1.36)) compared with those with fewer stools. CONCLUSION: The presence of MAM, dehydration or high stool frequency may be helpful in identifying children with MSD who might benefit from antibiotics.

Trajectories of asthma symptom presenting as wheezing and their associations with family environmental factors among children in Australia: evidence from a national birth cohort study.

OBJECTIVES: Asthma is one of the greatest health burdens, yet contributors to asthma symptom trajectories are understudied in Australian children. We aimed to assess the trajectories of asthma symptom and their associations with several family environmental factors during the childhood period in Australia. DESIGN: Secondary analysis from a cross-sequential cohort study. SETTING: Nationwide representative data from the 'Longitudinal Study of Australian Children (LSAC)'. PARTICIPANTS: Participants from the LSAC birth cohort. OUTCOME MEASURES: Asthma symptom trajectory groups. METHODS: Asthma symptom presenting as wheezing, family environmental factors and sociodemographic data (2004-2018) were obtained from the LSAC. Group-based trajectory modelling was applied to identify asthma symptom trajectories and multivariable logistic regression models were used to assess the associations between these and environmental factors. RESULTS: Of 5107 children in the LSAC cohort, 3846 were included in our final analysis. We identified three distinct asthma symptom trajectories from age 0/1 year to 14/15 years: 'low/no' (69%), 'transient high' (17%) and 'persistent high' (14%). Compared with the 'low/no' group, children exposed to 'moderate and declining' (relative risk ratio (RRR): 2.22, 95% CI 1.94 to 2.54; RRR: 1.26, 95% CI 1.08 to 1.46) and 'high and persistent' prevalence of maternal smoking (RRR: 1.41, 95% CI 1.23 to 1.60; RRR: 1.26, 95% CI 1.10 to 1.44) were at increased risk of being classified into the 'transient high' and 'persistent high' trajectories of asthma symptom. Persistently bad external dwelling conditions (RRR: 1.27, 95% CI 1.07 to 1.51) were associated with 'transient high' trajectory while 'moderate and increasing' conditions of cluttered homes (RRR: 1.37, 95% CI 1.20 to 1.56) were associated with 'persistent high' trajectory of asthma symptom. Exposure to tobacco smoke inside the house also increased the risk of being in the 'persistent high' trajectory group (RRR: 1.30, 95% CI 1.12 to 1.50). CONCLUSION: Poor home environment increased the risk of asthma symptom during childhood. Improving home environment and reducing exposure to tobacco smoke may facilitate a favourable asthma symptom trajectory during childhood.

Factors to be Considered in Advancing Pediatric Critical Care Across the World.

This article reviews the many factors that have to be taken into account as we consider the advancement of pediatric critical care (PCC) in multiple settings across the world. The extent of PCC and the range of patients who are cared for in this environment are considered. Along with a review of the ongoing treatment and technology advances in the PCC setting, the structures and systems required to support these services are also considered. Finally the question of how PCC can be made sustainable in a volatile world with the impacts of global crises such as climate change is addressed.

Household economic burden of childhood severe pneumonia in Bangladesh: a cost-of-illness study.

OBJECTIVE: To estimate household cost of illness (COI) for children with severe pneumonia in Bangladesh. DESIGN: An 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. SETTING: Four urban and rural study sites from two districts in Bangladesh. PATIENTS: Children aged 2-59 months with severe pneumonia. RESULTS: 1472 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. CONCLUSIONS: Severe 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.