Roger's Textbook of Pediatric Intensive Care - Chapter 2

Chapter 2
Pediatric Intensive Care: A Global Perspective
Trevor Duke
Niranjan Kissoon
Edwin Van DerVoort
During the last 100 years, Western countries have seen dramatic reductions in child mortality and overall improvements in child health, resulting from economic development, public health interventions, improved nutrition and maternal health, increased immunization and education, and advances in health technology and curative care. In the UK, North America, Australia, New Zealand, Japan, the Scandinavian countries, and Western Europe, child mortality rates fell from over 100 per 1000 live births at the end of the 19th century to less than 10 per 1000 live births at the beginning of the 21st century.
Pediatric intensive care played a small but significant role in these remarkable outcomes, although the majority of reductions in child mortality occurred long before the first use of prolonged per-laryngeal intubation of infants via polyvinyl chloride tubes in the early 1960s—the signal event that allowed children to be mechanically ventilated for prolonged periods without tracheostomy and thus heralded the development of PICUs (40). From 1960 through 1964, the under-5 mortality rate for 21 countries in Europe, North America, Australasia, and Asia that would go on to develop modern PICUs was 29 per 1000 live births [interquartile range (IQR), 24–34]. By 1999, the under-5 mortality rate for these countries was 7 per 1000 live births (IQR, 5.5–8) (1).
Despite these advances in rich countries, 90% of the world's children, the majority of whom live in developing countries and in the poorer areas of countries with mixed economies, have not shared in this remarkable prosperity and progress. The World Health Organization (WHO) estimates that, every year, more than 10 million children die; 99% of these deaths occur in developing countries (24,48). Figure 2.1 shows the distribution of child mortality globally, with the majority of under-5 deaths occurring in sub-Saharan Africa and South Asia. In 2001, 47 countries had child mortality rates >100 per 1000 live births. Ten countries—eight in sub-Saharan Africa—had mortality rates of >200 per 1000 live births.
For most children throughout the world, access to intensive care is nonexistent, and access to even basic healthcare is a challenge. In developing countries, most of the care of seriously ill children is provided by nurses, paramedic workers, and nonspecialist doctors in rural or remote hospitals or overcrowded urban hospitals. In most such hospitals, resources are inadequate, access to evidence and information is poor, and ongoing professional development and staff training are minimal (6,9). These basic deficiencies affect the lives of millions of children each year and are the backdrop to any consideration of the appropriate role of intensive care.
In an ideal world, good-quality intensive care would be available to all children. However, in those countries with limited resources, the provision of intensive care that will benefit only a few must be weighed against the greater needs of the many. Attending to less costly, but vitally important, basic healthcare needs reduces global inequity and may decrease the need for intensive care resources. An examination of the causes of global childhood mortality underscores this point.
Causes of Global Child Mortality
The major causes of death globally in children under 5 years of age are listed in Table 2.1 (48). Although not shown in the table, the proportions of deaths associated with these diseases are region specific, with skewed distribution on the African continent. For example, 94% and 89% of the world's malaria and HIV/AIDS deaths, respectively, occur in Africa.
More than 50% of children who die in developing countries have moderate or severe malnutrition, and malnutrition is implicated in deaths from diarrhea (61%), malaria (57%), pneumonia (52%), and measles (45%). Nearly 75% of the world's malnourished children live in 10 countries, and more than 99% live in developing countries (Fig. 2.2). Although children often present with a single condition (e.g., acute respiratory infection), those who are most likely to die often have experienced several other infections in recent months, have more than one current infection (e.g., pneumonia and diarrhea, or pneumonia and malaria), and have malnutrition with micronutrient (such as iron, zinc, or vitamin A) deficiency.
The World Health Organization's Approach to Global Child Mortality
In 2003, Lancet published a series on child survival, outlining the evidence for effective interventions in reducing child mortality. Twenty-three interventions (15 preventative and eight curative) that aimed at the commonest causes of child mortality had high-grade evidence for effectiveness, through large randomized trials or systematic reviews (24). These interventions were selected for being low cost and having potential for implementation at near universal scale in low-income countries. Some interventions protect against deaths from many causes. For example, breast-feeding protects against deaths from diarrhea, pneumonia, and neonatal sepsis; insecticide-treated materials (bed nets, sheets, etc.) protect against deaths from malaria and reduce deaths from preterm delivery. However, with the exception of breast-feeding (estimated global coverage of 90%), the global coverage of basic interventions for reducing child deaths from common conditions is low. The WHO/UNICEF Child Survival Strategy aims for the universal implementation of a basic package of interventions, along with advocacy for better health financing and a better political environment for child survival. The United Nations Millennium Development Goals contain benchmarks and targets for countries in reducing child mortality rates, with most countries aiming for a two-thirds reduction in under-5 mortality from the 1990 national figure, by 2015 (42).
A part of the Child Survival Strategy is integrated case management. To promote a comprehensive model of care for the sick child in 1995, WHO developed the Integrated Management of Childhood Illness (IMCI). IMCI focuses on primary healthcare workers managing the most important causes of childhood illness, including identification and treatment of children with multiple pathologies. An evaluation of IMCI in Bangladesh and Tanzania showed improvements in the quality of case management; now, over 90 countries have adopted the strategy, albeit often in pilot projects or with moderate coverage.
In recognizing the need for effective referral services, WHO has produced complementary guidelines on pediatric care for district or provincial hospitals (47). These guidelines emphasize that diagnosis and drug treatment are not in themselves sufficient for the optimal care of the seriously ill child, but that triage, emergency care, supportive care (including oxygen, nutrition, safe administration of IV fluids), monitoring, discharge planning, and follow-up are also essential. These processes of care were found to be deficient in audits of practice in many developing and transitional countries (8,11,32). Increasing evidence demonstrates that triage and emergency care (29), as well as standardized management of severe malnutrition (2,36,45), severe pneumonia (7), and neonatal conditions (10), can reduce in-hospital mortality.
Standardized management includes high-dependency care and general intensive care with capability for postoperative surgical management of children (46).
Ethics of Providing Pediatric Intensive Care in Developing Countries
When countries have child mortality rates of >30 per 1000 live births, a major proportion of child deaths will be preventable or treatable by simple measures, such as immunization, primary care, and basic curative services in hospitals. In these situations, expending vast resources on intensive care in tertiary institutions accessible to only a small proportion of children does not make sense when simpler and cheaper life-saving treatments are not available to a substantial proportion of the child population. Moreover, child mortality rates are not evenly distributed: Within most countries, some regions or districts have higher mortality rates and others have lower mortality rates than the national average. The factors behind such uneven distribution of mortality rates include poverty, lack of access to services, minority groups, and geographical isolation.
An ethical approach to intensive care is, therefore, problematic. Is it appropriate to provide intensive care to children in middle-class urban areas that have low child mortality rates when children in remote rural areas or urban slums do not have access to basic health interventions? Ethical considerations are not constrained by national boundaries, although practical decisions of resource distribution invariably are. Should a child in a rich Western country receive surgery for hypoplastic left heart syndrome when children in poor developing countries do not have access to surgery for simple cardiac anomalies, such as a ventricular septal defect, or do not have access to antibiotics when they have pneumonia? To a large extent, questions of equity of access and disparity between countries are tempered by practical realities. If children in Western countries were not offered palliative surgery for complex cardiac disease, this would not mean that children in developing countries would necessarily be more likely to receive surgery for cardiac defects with better prognoses. These ethical dilemmas will remain as long as vast income inequity and extreme poverty exist in the world, but they can be partially addressed through greater global cooperation and collaboration between child health institutions and through greater generosity by rich governments in the provision of overseas developmental aid.
The main argument against providing intensive care in high-mortality areas is that doing so would divert scarce resources away from more effective low-cost interventions. Following the principles of equity, countries should ensure that highly cost-effective health interventions that will reduce mortality are available to all children, before funding intensive care services. In very poor countries, evidence of extremely high mortality rates and low occupancy rates (because of inability to pay) in adult ICUs emphasizes the limited value of intensive care services to population health in these settings (33).
Based on the principle of distributive justice, some authors have argued for defining, based on the nation's resources, a minimum level of care that must be available for all children (38). In India, for example, it has been suggested that oxygen, intravenous access and fluid resuscitation, antibiotics, and noninvasive application of continuous positive airway pressure in a clean environment be considered the minimum level of intensive care support that should be made available to all children (38). In South Africa, the HIV epidemic has placed a large burden on pediatric intensive care (23,49) and raised complex ethical issues. Some authors have suggested a utilitarian approach, whereby it is ethically defensible to refuse to ventilate children with severe HIV-associated pneumonia if the resources for doing so are redirected toward programs aimed at preventing mother-to-child transmission (22). Such decisions can never be made over an individual case, but rather can only be decided after consideration of the issues of justice and broader health policies.

Good practical and ethical arguments exist for providing selective and limited postoperative intensive care services, even where national or regional mortality rates are high. Many patients who have undergone surgery die for lack of appropriate supportive care, including mechanical ventilation, in the first 24 postoperative hours. WHO suggests that facilities for intensive care should be available in any hospital where surgery and anesthesia are performed, and it has published standards for PICUs in large referral hospitals, district/provincial hospitals, and small hospitals in developing countries (46). These standards outline conditions that should be able to be managed, procedures that should be able to be performed, and personnel, drugs, and equipment that are necessary. Where mechanical ventilation is available, there is a good basis for providing intensive care for a few selected other nonsurgical conditions, particularly neuromuscular paralysis after snake bite, which is time limited and likely to result in a good outcome if appropriate supportive care is provided.
Intensive care engenders major dilemmas in expectations of survival and extent of treatment. In developing countries, parents often have more conservative attitudes toward withdrawal of life support than do the treating clinicians, who in general have a more utilitarian attitude to resource allocation, with emphasis toward avoidance of significant handicap (44). Limitation of treatment is the most commonly reported mode of death in PICUs in developing countries, and active withdrawal is not widely practiced (18). These issues present ethical as well as resource implications and must be considered when planning pediatric intensive care services for areas with limited human, technical, and financial resources.
In providing equitable pediatric intensive care, indications for admission should be severity of illness and likelihood of a good outcome, and admission or access to treatment should not be limited by inability to pay. In developing countries, serious childhood illness is a major economic burden on many families, especially if care for the child is provided away from the community. The need to cease work and to pay for transport, admission, and expensive prolonged treatment can lead to a cycle of poverty and poor health that affects the entire family.
Experiences of Pediatric Intensive Care in Transitional or Mixed Economies
Transitional countries in Asia and the Americas, as well as South Africa, which has a wide range of economic and health development, have introduced pediatric intensive care services during the last two decades. The limiting factors to quality of care that were identified in South America included inadequate interdepartmental organization, lack of treatment protocols, too few pediatric intensivists, inferior equipment, lack of qualified technicians, and lack of training and recognition of pediatric intensive care nurses. A standard of quality in the PICU was proposed, with highest priority given to the training and certification of intensive care specialists, nurses, and residents; administration; supervision; protocol development; and upgrading of equipment (13). The development of pediatric intensive care has also been well documented in Malaysia (16,17). In Kuala Lumpur, introduction of 24-hour staffing by critical care physicians reduced the case-mix–adjusted mortality. Each of these structural and organizational issues was considered to be far more important than was invasive hemodynamic monitoring or costly drugs and equipment.
Nosocomial sepsis is an ever-present danger in PICUs, and has been a feature of pediatric and neonatal ICUs in developing countries (21,25,28,31). Strictly applied evidence-based antibiotic policies, hand washing, and other infection-control procedures are vital to ensure patient safety, and these should be cornerstones of intensive care. However, studies have shown that it is difficult to directly implement and sustain Western guidelines for the prevention of nosocomial infections in PICUs in developing countries; they have further shown that adapted, locally appropriate guidelines should be further studied and that the importance of institutional commitment to infection control and microbiology services should be emphasized (4,37).
Models of pediatric intensive care in developing and industrialized countries that are designed to minimize risk should include the use of safe and simple procedures for appropriate periods, with particular attention to drug prescribing and selection of appropriate aims and modes of therapy, including noninvasive methods (12).
Regionalization or Decentralization
Strong evidence from Western countries demonstrates that the centralization of pediatric intensive care services results in lower mortality than do decentralized or fragmented services (35). However, several prerequisites accompany centralized services, including transportation to a tertiary hospital from peripheral facilities and appropriate pretransport management (14). In many developing countries, roads are poor, appropriate vehicles are often not available, and fuel costs are prohibitive (5). Families may be required to pay fuel costs or a transportation fee—another impediment to access. If transportation is not freely available, pediatric intensive care will not fulfill the principle of equity, because it will not be accessible to a large portion of the population. Furthermore, children from remote areas may die in transit as their families attempt to transport them to the hospital themselves. Appropriate pretransport management requires good communication infrastructure and, for peripheral hospitals in many countries, improved quality of basic emergency care. Both needs should be addressed before, or in parallel with, the development of pediatric intensive care services.
In Malaysia, the outcome for children transferred from community hospitals by nonspecialized transport was no different from that of children directly admitted to the PICU from within the tertiary institution (15), but this study did not take into account the critically ill children who never reached the tertiary center. In the same country, the outcome from major trauma managed in district hospitals is significantly worse than the outcome from major trauma in adults and children managed in tertiary centers, emphasizing the benefit of centralized management of acute severe illness, when possible, and the importance of improving the quality of care in district hospitals, regardless of whether care is regionalized or decentralized (39). Planning for intensive care should take into consideration the entire spectrum of services necessary to care for the critically ill (26), including prehospital resuscitation, transport, and subspecialty support services.

Neonatal Mortality
More than one-third of deaths in the under-5 age group occur during the first month of life (see Table 2.1), and the majority of neonatal deaths occur within the first few days of birth. Most of the 3.9 million annual neonatal deaths occur in socioeconomic deprivation in developing countries. Programs to improve neonatal survival focus on supervised clean deliveries, essential care of the newborn (early breast-feeding, skin-to-skin warmth), steroids for preterm labor, antibiotics for premature rupture of membranes, maternal tetanus toxoid to prevent neonatal tetanus, prevention of mother-to-child transmission of HIV, and identification of sick neonates who require referral to hospitals.
Recently, the WHO produced guidelines for the management of seriously ill neonates in hospitals in developing countries (47). Hospital care for seriously ill neonates should focus first on high-dependency care, including evidence-based antibiotic prescribing, prevention of nosocomial infections, enteral nutrition, safe use of oxygen and intravenous fluids, staff training, audit, and management (10). Where staff resources are limited, involving mothers in high-dependency care has been shown to be highly effective (3). When these interventions are conducted optimally, the introduction of nasal continuous positive airway pressure may be the most effective initial approach to ventilatory support (27). The literature contains many reports concerning neonatal intensive care in developing countries (20,41,43) and the debate about regionalization of care (34), but these are beyond the scope of this chapter.
As neonatal mortality falls, resources must be available to deal with the increased morbidity that will occur in survivors, including malnutrition, chronic lung disease, and neurologic disease among survivors of prematurity. These morbidities have implications for pediatric services, including intensive care.
The Role of Pediatric Intensive Care in Complex Emergencies
Complex emergencies are identified as acute situations that involve excess mortality (>1 death per 10,000 per day). They may be due to natural (e.g., earthquake, floods, tsunami) or unnatural (war, famine) disasters, or both. Complex emergencies are dynamic, with variable durations, recovery, resettlement, rehabilitation, and development phases. After the initial disaster, high mortality rates are usually due to diarrheal disease (including cholera and dysentery), measles, malaria, meningococcal disease, tuberculosis, neonatal causes, trauma, malnutrition, and micronutrient deficiency (30). The United Nations High Commission for Refugees estimates that such circumstances affect up to 10 million people per year.
Many factors impede the delivery of healthcare in such situations, including lack of human resources and referral services, security constraints, poor supervision and coordination, and failure of integration with local health services or transition to a sustainable health system. In addition, lack of evidence-based, locally adapted guidelines limit the effectiveness of healthcare in these situations and contribute to the chaos (30). The first priority in complex emergencies will be management of the initial casualties, for which good emergency care systems and trauma management are vital (19), and intensive care, especially for postoperative management, is optimal. After the immediate emergency phase, high mortality rates in complex emergencies will be addressed through public health measures and developing basic services.
Conclusions and Future Directions
The development of pediatric intensive care services should take into account the level of preventative and basic curative treatment available to all children in the subject country, as well as the national and regional mortality rates. Preexisting conditions for pediatric intensive care are good vaccine services, good-quality primary and first-referral level care, under-5 mortality rates of <30 per 1000 live births, availability of transportation, good access for the majority of the population, and sufficient human resources. Some form of intensive care, with capacity for management of children after surgery, should be available in any hospital where surgery

and anesthesia are performed.
Hospitals should be recognized by governments and communities as core social institutions. The quality of care provided in hospitals—and the nature of interactions between health systems, patients, and their families—have major consequences for child health and survival, human rights, poverty alleviation, and development. In developing and transitional countries, pediatric intensive care specialists possess the potential to improve the management of seriously ill children throughout their countries by training staff in smaller hospitals, by encouraging the building of effective emergency health systems for children, and by providing high-quality clinical care in tertiary settings that have PICUs.
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