Elsevier

The Lancet

Volume 381, Issue 9862, 19–25 January 2013, Pages 256-265
The Lancet

Review
Global paediatric advanced life support: improving child survival in limited-resource settings

https://doi.org/10.1016/S0140-6736(12)61191-XGet rights and content

Summary

Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries. The leading causes of mortality in children younger than 5 years worldwide, pneumonia and diarrhoeal illness, account for 1·396 and 0·801 million annual deaths, respectively. Although important advances in prevention are being made, advanced life support management in children in developing countries is often incomplete because of limited resources. Existing advanced life support management guidelines for children in limited-resource settings are mainly empirical, rather than evidence-based, written for the hospital setting, not standardised with a systematic approach to patient assessment and categorisation of illness, and taught in current paediatric advanced life support training courses from the perspective of full-resource settings. In this Review, we focus on extension of higher quality emergency and critical care services to children in developing countries. When integrated into existing primary care programmes, simple inexpensive advanced life support management can improve child survival worldwide.

Introduction

In developing countries, important progress has been made over the past few decades in the treatment of critically ill children. In these countries, the burdens of global paediatric population, life-threatening disease, and mortality are the greatest; low living standards and poor hygiene, combined with widespread malnutrition and multiple concurrent illnesses, further increase the complexity of disease.1, 2, 3 Advancements in the management of severe infection and shock have been achieved with the introduction of paediatric critical care medicine and recommendations endorsed by WHO.4 Despite much effort to guide health-care practitioners in the care of children with serious conditions, progress towards a substantial reduction in global mortality in children younger than 5 years has been disappointing.5, 6, 7 Limitations in resources and poor health-care systems in developing countries jeopardise critically ill children whose survival depends on timely attention to life support. Development of more effective paediatric emergency and critical care services in developing countries has been identified as crucial to substantially reduce global mortality in children younger than 5 years.8 Toward this end, paediatric advanced life support, broadly defined as emergency management beyond cardiopulmonary resuscitation or automated external defibrillator in children outside the neonatal period, can be improved in limited-resource settings. In this Review, we provide an overview of paediatric advanced life support management in limited-resource settings, with a focus on recent developments and proposed solutions.

Section snippets

Improvement of paediatric advanced life support management with increased access to resources

Paediatric advanced life support management in developing countries, if practised, is often incomplete because of low availability of resources, including limitations in disease surveillance and reporting systems, referral services from primary health centres, structural models for emergency medical services, transport services, emergency care centres, triage systems, trained health-care professionals in paediatric emergency and critical care medicine, hospital infrastructure for critically ill

Modification of international advanced life support guidelines to represent a different disease range

The disease range in children in limited-resource settings differs from that of developing countries. Many existing advanced life support guidelines are applicable to developed countries, but efforts are underway to create separate guidelines for children with unique presentations common to low-income countries.16, 36, 37 Examples of these unique presentations that potentially require different advanced life support management compared with traditional recommendations originating in developed

Reduction of global paediatric mortality with simple, inexpensive treatment

Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries: 49% in sub-Saharan Africa, 33% in south Asia, and 17% in other regions.6 The leading causes worldwide are pneumonia and diarrhoeal illness, accounting for about 1·396 million and 0·801 million deaths every year, respectively.56 The global burden of these diseases occurs disproportionately in settings where limitations in health-care resources are greatest.1, 5

To achieve United Nations Millennium

Inclusion of entire continuum of care in advanced life support guidelines

Universally, poor-quality care has the most severe consequences for children with time-sensitive critical conditions—eg, severe infection, hypoxia due to respiratory illness, hypovolaemia due to diarrhoea, and injury (both accidental and non-accidental).8, 10, 26 Ideally, paediatric advanced life support training and management guidelines in limited-resource settings should be expanded to the entire continuum of care of critically ill children. The model continuum of care, from pre-hospital

Standardisation of advanced life support management

Existing advanced life support management in children in limited-resource settings is not standardised with a systematic approach to patient assessment and categorisation of illness.8, 15, 18, 30 No standardisation could result in under-recognition of severe clinical illness (eg, hypoxaemia, pneumonia, and shock).26, 79, 80 A systematic approach to patient assessment and accurate categorisation of illness could result in early recognition of critical disorders, appropriate treatment, and

Expansion of the usefulness of existing paediatric advanced life support courses

Existing advanced life support guidelines for children as taught in present paediatric advanced life support courses are mostly applicable to settings that have full resources. For this reason, these advanced life support courses do not have universal applicability, despite their international acceptance.18, 32, 70, 75, 76, 83 Furthermore, the effectiveness of these courses in improving outcomes in developing countries has not been shown.84 A revised curriculum with evidence-based application

Establishment of international, evidence-based advanced life support guidelines

Many existing advanced life support guidelines for children in limited-resource settings are empirical, rather than evidence-based.24, 102 Examples include: avoidance of oxygen masks for free-flow oxygen delivery; use of small intravenous fluid boluses and thereafter blood transfusion in severe acute malnutrition and shock; and widespread use of broad-spectrum antibiotics in sepsis.16, 102, 108

Justification for empirical guidelines includes both pragmatism in limited-resource settings (eg, an

Conclusions

Over the past decades, advanced life support management has contributed to a substantial reduction in child mortality in developed countries. Securing of real progress toward a global reduction in mortality in children younger than 5 years will need continued and improved efforts at both the prevention and treatment of life-threatening disorders. Paediatric emergency and critical care is limited in the regions of the world where nearly all global childhood deaths occur. Improvement in

Search strategy and selection criteria

We searched the Cochrane Library, PubMed (Medline), and Embase databases from 1945 to December, 2011. We used the Medical Subject Headings (MeSH) terms “respiration disorders”, “arrhythmias, cardiac”, “heart arrest”, “shock”, “pneumonia”, or “diarrhea”, and the keywords “respirat*”, “heart”, “cardiac”, “shock”, “pneumonia”, “diarrhea”, “gastroenteritis”, “emergenc*”, “triage”, or “resuscitat*”. These results were limited to include children younger than 12 years of age and focused on developing

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