An exploratory assessment of the management of pediatric traumatic brain injury in three centers in Africa.

Purpose: Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in low- and middle-income countries (LMICs). Hospital care practices of pediatric TBI patients in LMICs are unknown. Our objective was to report on hospital management and outcomes of children with TBI in three centers in LMICs. Methods: We completed a secondary analysis of a prospective observational study in children (<18 years) over a 4-week period. Outcome was determined by Pediatric Cerebral Performance Category (PCPC) score; an unfavorable score was defined as PCPC > 2 or an increase of two points from baseline. Data were compared using Chi-square and Wilcoxon rank sum tests. Results: Fifty-six children presented with TBI (age 0-17 y), most commonly due to falls (43%, n = 24). Emergency department Glasgow Coma Scale scores were ≤ 8 in 21% (n = 12). Head computed tomography was performed in 79% (n = 44) of patients. Forty (71%) children were admitted to the hospital, 25 (63%) of whom were treated for suspected intracranial hypertension. Intracranial pressure monitoring was unavailable. Five (9%, n = 5) children died and 10 (28%, n = 36) inpatient survivors had a newly diagnosed unfavorable outcome on discharge. Conclusion: Inpatient management and monitoring capability of pediatric TBI patients in 3 LMIC-based tertiary hospitals was varied. Results support the need for prospective studies to inform development of evidence-based TBI management guidelines tailored to the unique needs and resources in LMICs.

Family-Assisted Severity of Illness Monitoring for Hospitalized Children in Low-Resource Settings-A Two-Arm Interventional Feasibility Study.

Introduction: Pediatric mortality remains unacceptably high in many low-resource settings, with inpatient deaths often associated with delayed recognition of clinical deterioration. The Family-Assisted Severe Febrile Illness ThERapy (FASTER) tool has been developed for caregivers to assist in monitoring their hospitalized children and alert clinicians. This study evaluates feasibility of implementation by caregivers and clinicians. Methods: Randomized controlled feasibility study at Kenyatta National Hospital, Kenya. Children hospitalized with acute febrile illness with caregivers at the bedside for 24 h were enrolled. Caregivers were trained using the FASTER tool. The primary outcome was the frequency of clinician reassessments between intervention (FASTER) and standard care arms. Poisson regression with random intercept for grouping by patient was used, adjusting for admission pediatric early warning score, age, gender. Secondary outcomes included survey assessments of clinician and caregiver experiences with FASTER. Results: One hundred and fifty patient/caregiver pairs were enrolled, 139 included in the analysis, 74 in the intervention, 65 in the control arm. Patients' median age was 0.9 (range 0.2-10) and 1.1 years (range 0.2-12) in intervention vs. control arms. The most common diagnoses were pneumonia (80[58%]), meningitis (58[38%]) and malaria (34 [24%]). 134 (96%) caregivers were patients' mothers. Clinician visits/hour increased with patients' illness severity in both arms, but without difference in frequency between arms (point estimate for difference -0.9%, p = 0.97). Of the 16 deaths, 8 (four/arm) occurred within 2 days of enrollment. Forty clinicians were surveyed, 33 (82%) reporting that FASTER could improve outcomes of very sick children in low-resource settings; 26 (65%) rating caregivers as able to adequately capture patients' severity of illness. Of 70 caregivers surveyed, 63 (90%) reported that FASTER training was easy to understand; all (100%) agreed that the intervention would improve care of hospitalized children and help identify sick children in their community. Discussion: We observed no difference in recorded frequency of clinician visits with FASTER monitoring. However, the tool was rated positively by caregivers and clinicians., Implementation appears feasible but requires optimization. These feasibility data may inform a larger trial powered to measure morbidity and mortality outcomes to determine the utility of FASTER in detecting and responding to clinical deterioration in low-resource settings. Clinical Trial Registration: ClinicalTrials.gov, identifier: NCT03513861.

Feasibility of Family-Assisted Severity of Illness Monitoring for Hospitalized Children in Low-Income Settings.

OBJECTIVES: To determine the feasibility of having caregivers assist in recognition of clinical deterioration in children hospitalized with febrile illness in a resource-limited setting. DESIGN: Single-center, prospective, interventional pilot study. SETTING: General pediatric wards at Kenyatta National Hospital, Nairobi, Kenya's largest public tertiary-care hospital. PATIENTS: Children hospitalized with acute febrile illness, accompanied by caregivers available at the bedside for 24 hours soon after hospital admission. INTERVENTIONS: Caregivers were trained to recognize signs of critical illness using the Family-Assisted Severe Febrile Illness Therapy tool, which quantifies patients' work of breathing, mental status, and perfusion, producing color-coded flags to signal illness severity. Caregivers' Family-Assisted Severe Febrile Illness Therapy assessments were compared with healthcare professional assessments and to established Pediatric Early Warning Scores (PEWS). An initial study stage was followed by refinement of training and a larger second stage with intervention/control arms. MEASUREMENTS AND MAIN RESULTS: A total of 107 patient/caregiver pairs were enrolled in the interventional arm; 106 caregivers underwent Family-Assisted Severe Febrile Illness Therapy training and were included in the analysis. Patient characteristics included median age 1.1 years (0.2-10 yr), 55 (52%) female, and diagnoses: pneumonia (64 [60%]), meningitis (38 [36%]), gastroenteritis (24 [23%]), and malaria (21 [20%]). Most caregivers had primary (34 [32%]) or secondary (53 [50%]) school education. Fourteen of 106 patients (13%) died during their stay, six within 2 days. Across all severity levels, caregiver Family-Assisted Severe Febrile Illness Therapy assessments matched professionals in 87% and 94% for stages 1 and 2, respectively. Caregiver Family-Assisted Severe Febrile Illness Therapy assessments had a moderate to strong correlation with coinciding Pediatric Early Warning Scores and were sensitive to life-threatening deterioration: for all six patients who died within 2 days of admission, caregiver assessment reached the highest alert level. CONCLUSIONS: Caregiver involvement in recognition of critical illness in hospitalized children in low-resource settings may be feasible. This may facilitate earlier detection of clinical deterioration where staffing is severely limited by constrained resources. Further validation of the Family-Assisted Severe Febrile Illness Therapy tool is warranted, followed by its application in a larger multisite patient population to assess provider response and associated clinical outcomes.

Feasibility of high-flow nasal cannula implementation for children with acute lower respiratory tract disease in rural Kenya.

Background: High-flow nasal cannula (HFNC) is a well-established respiratory support device in high-income countries, but to our knowledge, its use in sub-Saharan Africa has not been reported. This feasability study describes the implementation process of HFNC in rural Kenya. Methods: HFNC was implemented in intensive care and high dependency units at Kijabe Hospital, Kenya for children with acute lower respiratory disease. Rate of intubation was compared with historical controls and challenges of implementation described. Results: Fifteen patients received HFNC between January and November 2016, and compared to 25 historical control patients. Both groups had many comorbidities, and control patients were significantly younger. There were no significant differences in clinical outcome between the groups: 5 (33%) HFNC vs 12 (48%) controls required intubation; 10 (67%) HFNC vs 22 (88%) controls survived to discharge; and the HFNC required 3 vs the controls' 4 days on respiratory support. The greatest technical issues encountered were large pressure differences between air from a wall outlet (wall air) and oxygen and an inability to automatically refill humidifier water chambers. Conclusion: HFNC in limited-resource settings is feasible but there were technical challenges and concern about the increased workload. The small sample size, heterogeneous population, availability of oxygen and blending of wall air at the study site limit inferences for other sites in low- and middle-income countries. Abbreviations: ALRI, acute lower respiratory infection; CPAP, continuous positive airway pressure; ETAT, emergency triage, assessment and treatment; HDU, high dependency unit; HFNC, high-flow nasal cannula; HIC, high-income country; HR, heart rate; ICU, intensive care unit; LMIC, low- and middle-income countries; PSI, pounds per square inch; RR, respiratory rate; mRISC, modified Respiratory Index of Severity in Children.

Challenges and Priorities for Pediatric Critical Care Clinician-Researchers in Low- and Middle-Income Countries.

INTRODUCTION: There is need for more data on critical care outcomes and interventions from low- and middle-income countries (LMIC). Global research collaborations could help improve health-care delivery for critically ill children in LMIC where child mortality rates remain high. MATERIALS AND METHODS: To inform the role of collaborative research in health-care delivery for critically ill children in LMIC, an anonymous online survey of pediatric critical care (PCC) physicians from LMIC was conducted to assess priorities, major challenges, and potential solutions to PCC research. A convenience sample of 56 clinician-researchers taking care of critically ill children in LMIC was targeted. In addition, the survey was made available on a Latin American PCC website. Descriptive statistics were used for data analysis. RESULTS: The majority of the 47 survey respondents worked at urban, public teaching hospitals in LMIC. Respondents stated their primary PCC research motivations were to improve clinical care and establish guidelines to standardize care. Top challenges to conducting research were lack of funding, high clinical workload, and limited research support staff. Respondent-proposed solutions to these challenges included increasing research funding options for LMIC, better access to mentors from high-income countries, research training and networks, and higher quality medical record documentation. CONCLUSION: LMIC clinician-researchers must be better empowered and resourced to lead and influence the local and global health research agenda for critically ill children. Increased funding options, access to training and mentorship in research methodology, and improved data collection systems for LMIC PCC researchers were recognized as key needs for success.