Hospital services for children in the Solomon Islands: rebuilding after the civil conflict

AIMS: The Solomon Islands health service, infrastructure and economy were severely affected by the civil conflict that occurred between 1998 and 2003. In 2002 plans to rebuild health services for children, especially those provided in provincial hospitals, were developed by paediatricians, in collaboration with the World Health Organization. We aimed to inform this process by an assessment of the strengths and weaknesses of the child health service, particularly in provincial hospitals. METHODS: A systematic assessment of the quality of hospital care for children in Solomon Islands was conducted in November 2003. The study used a WHO assessment tool, modified for use in the Asia-Pacific region. RESULTS: The assessment highlighted several problems in clinical care, human resources, health financing, referral systems, and training, and has been used as a basis for several interventions for improving the quality of paediatric care. CONCLUSION: This study and the initiatives that have followed it demonstrate the link between such assessments, child health policy and quality improvement activities. Such programs can be implemented even where resources are very limited. Sustaining initiatives based on this assessment will be important for the Solomon Islands if it is to achieve the Millennium Development Goals for child survival by 2015.     

Reducing newborn mortality in the Asia–Pacific region: Quality hospital services and community‐based care

Improving newborn health and survival is an essential part of progression toward Millennium Development Goal 4 in the World Health Organization Western Pacific and South East Asian regions. Both community and facility‐based services are required. Strategies to improve the quality of care provided for newborns in health clinics and district‐ and referral‐level hospitals have been relatively neglected in most countries in the region and in the published literature. Indirect historical evidence suggests that improving facility‐based care will be an increasing priority for improving newborn survival in Asia and the Pacific as newborn mortality rates decrease and health systems contexts change. There are deficiencies in many aspects of newborn care, including immediate care and care for seriously ill newborns, which contribute substantially to regional newborn morbidity and mortality. We propose a practical quality improvement approach, based on models and standards of newborn care for primary‐, district‐ and referral‐level heath facilities and incorporated within existing maternal, newborn and child health programmes. There are examples where such approaches are being used effectively. There is a need to produce more nurses, community health workers and doctors with skills in care of the well and the sick newborn, and there are World Health Organization models of training to support this, including guidelines on emergency obstetric and newborn care and the Pocket Book of Hospital Care for Children. There are also simple data collection and analysis programmes that can assist in auditing outcomes, problem identification and health services planning. Finally, with increased survival rates there are gaps in follow‐up care for newborns at high risk of long‐term health and developmental impairments, and addressing this will be necessary to ensure optimal developmental and health outcomes for these children.     

Malnutrition: a secular challenge to child nutrition

OBJECTIVE: To review current knowledge about child malnutrition, including the historical aspects of the problem, its dimension as a childhood public health problem, its natural history, physiopathology, clinical features, diagnosis and treatment, and strategies used by the health sector to control this disease. METHODS: Information was collected by researching the Medline system, the Bireme library, internet sites of interest, catalogues of publications produced by Brazilian governmental organizations and international institutions dealing with child nutrition. RESULTS: The review pointed out that despite recent world prevalence reduction, child malnutrition is a major public health problem in developing countries. Malnutrition, in any of its forms, contributes for more than 50% of deaths among children under 5 years in those countries. Mortality rates of severely malnourished children treated as in patients have been unchanged for the last five decades. Guidelines for improving the treatment and reducing mortality rates of severely malnourished children treated in hospitals were recently defined by the World Health Organization. Even though some positive results have been achieved by the health sector in reducing child malnutrition prevalence, the effectivity of the interventions is often low. Lack of food might limit the success in treating and preventing malnutrition. Factors that may contribute to the effectiveness of interventions against malnutrition include approaches which reassure the confidence of health professionals about achieving positive results with the proper treatment of malnourished children, establishment of an effective relationship between health professionals and mothers, as well as practical support to mothers in recognizing them as valuable active agents for their children nutrition rehabilitation at the household level. CONCLUSIONS: Throughout the centuries, malnutrition has been the biggest challenge faced by developing countries in order to guarantee to children under five years of age their right of being well nourished and healthy. The current challenge is the proper use of the available scientific knowledge on child nutrition to further reduce the figures for all the types of child malnutrition.     

The World Health Organization child growth standards: expected implications for clinical and epidemiological research

In 2006 and 2007, the World Health Organization (WHO) released two sets of child growth standards (World Health Organization, WHO Child Growth Standards. Methods and development. Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. WHO, Geneva, 2006; World Health Organization, WHO Child Growth Standards: Methods and Development. Head circumference-for-age, arm circumference-for-age, triceps skinfold-for-age and subscapular skinfold-for-age. WHO, Geneva, 2007) to replace the National Center for Health Statistics references (Hamill et al., National Center for Health Statistics, Vital and Health Statistics Series 11, No 165, 1977) as an international tool for growth and nutritional assessment. This paper explores the scope of implications for future anthropometric research, highlighting foreseeable effects on the choice of research questions, choice of nutritional indices, training of measurers, and issues of internal and external validity of research results. The conclusion drawn is that the introduction of the WHO child growth standards is expected to have wide implications for growth and nutrition research. The full scope of this effect will gradually become clear while researchers, similar to health care workers, make the transition to using the new standards, re-evaluate results of past approaches, and explore the uses and functional validity of the standards, including those for indices that were not previously available.     

Essential newborn care training activities: 8 years of experience in Eastern European, Caucasian and Central Asian countries

There is still an alarming gap in neonatal healthcare and outcome between Western and Eastern European countries and the former USSR countries in particular. Most of the causes of neonatal mortality and morbidity can be prevented or managed by simple cost-effective interventions aimed at improving quality of healthcare, health system organisation and family and community participation. Training of health professionals and health policy-makers in the field of essential neonatal care and breastfeeding promotion is one of the cornerstones of the World Health Organization (WHO) initiatives Making Pregnancy Safer (MPS) and Promoting Effective Perinatal Care (PEPC) - the latter specifically tailored to the European Region - aimed at ensuring safe pregnancy and childbirth through ensuring the availability, access and use of quality skilled care. After 8 years of experience of training in essential neonatal care, positive changes in planning for and delivering neonatal care are taking place, even in challenging contexts, and this model of intervention should be further implemented in the region.     

PAEDIATRIC EDUCATION PRIORITIES IN ASIA AND THE WESTERN PACIFIC REGION

Based on the most recently available statistical information an attempt has been made to define priorities in medical education programmes, especially in relation to maternal and child health in several countries of the Western Pacific Region including South East Asia. Sources of data are the ministries of health and medical schools of the regional countries as well as participants in the recent World Health Organization travelling seminar series on paediatric education held in countries of the Western Pacific Region. Opinions expressed in this article are personal and do not necessarily reflect the official policy of the World Health Organization.     

The girl child and her equal right to ''first call'' for children

Using the life-cycle approach, the problems of the girl child are summarized. A number of recommendations are put forward. Also enumerated are tasks that child health care providers can focus on to address these problems. Pertinent United Nations initiatives for the protection of women/girls are listed, in addition to the output of a pre-Congress workshop on the girl child sponsored by the International Pediatric Association, the World Health Organization and UNICEF.     

What will it take to stop the needless deaths of millions of women and children each year?

Each year, almost 10 million children die before their fifth birthday; the majority from easily preventable diseases such as diarrhoea, pneumonia and malaria. Furthermore, 10 million women endure pregnancy‐related morbidities annually while 500,000 die in childbirth. The link between maternal and child health is inextricable and worldwide inequities continue to widen: 99% of all neonatal deaths occur in developing countries, while maternal mortality rates are 1,000 times greater for women in poor countries compared to those living in rich nations. These discrepencies continue to persist despite the presence of a multitude of simple, cost‐effective interventions which could save the lives of millions of women and children worldwide each year for a fraction of the cost associated spent on health care in the developed world.     

Acute malnutrition in Latin America: the challenge of ending avoidable deaths

In Latin America and the Caribbean, malnutrition still represents a health concern expressed mainly as stunting and micronutrient deficiencies, lessening the attention given to acute malnutrition (moderate and severe); however, the latter has a high fatality rate. Ending these avoidable deaths represents a major health and ethical challenge in the region. Acute malnutrition plus infections (mainly diarrhea and pneumonia) determine an important fraction of the fatality rate due to malnutrition in most regions, especially those with higher poverty and social instability. Application of the World Health Organization guidelines for the treatment of children with acute severe malnutrition reduces the fatality rate significantly. Among the many possibilities for treatment, systems based on day care centers and at home should be promoted. Training in the application of the World Health Organization guidelines should be incorporated into the curricula of health-related professions in countries where malnutrition is prevalent.     

Standardized diagnosis of pneumonia in developing countries.

The World Health Organization recommends the use of raised respiratory rate and chest wall indrawing to enable health workers in developing countries to diagnose pneumonia. We evaluated the current World Health Organization guidelines for management of the child with cough or difficult breathing in Manila, Philippines and Mbabane, Swaziland using an identical protocol in both countries. Raised respiratory rate was defined as greater than or equal to 50/minute for children ages 2 to 12 months and greater than or equal to 40/minute for children 12 months to 5 years. Chest wall indrawing was defined as inward movement of the bony structures of the lower chest wall with inspiration. In the Philippines raised respiratory rate or chest wall indrawing, when applied by a pediatrician, was found to have a sensitivity of 0.81 and specificity of 0.77 for predicting pneumonia as determined by a pediatrician with the aid of a chest roentgenogram. In Swaziland the sensitivity was 0.77 and the specificity was 0.80. When applied by health workers the sensitivity was similar but the specificity was lower. The current World Health Organization ARI case management guidelines predicted pneumonia with similar sensitivity and specificity in two very different developing countries, the Philippines and Swaziland.     

Inequities in neonatal survival interventions: evidence from national surveys

BACKGROUND: Nearly four million children die during the first four weeks of life every year, yet known and effective interventions exist. Neonatal mortality has to be addressed to reach the millennium development goal for child survival. AIMS: To determine the extent of within-country inequities in neonatal mortality and effective intervention coverage. METHODS: Neonatal, infant and child (under 2 years) mortality rates were calculated from empirical data from Demographic and Health Surveys for eight countries using direct estimation techniques. Wealth groups were constructed using the World Bank wealth index; neonatal mortality inequities were evaluated by comparing low:high quintile ratios; concentration indices were calculated for intervention coverage rates. RESULTS: The proportion of under-2 deaths occurring in the neonatal period ranged from 24.3% (Malawi) to 49.4% (Bangladesh). In all countries (excluding Haiti) inequities in neonatal mortality and intervention coverage were evident across wealth groups with more deaths and less coverage in the poorest, compared with the richest, quintile; the largest mortality differential was 2.1 (Nicaragua) and the smallest was 1.2 (Eritrea). In Nicaragua 33% of the poorest women had a skilled delivery compared with 98% of the richest; in Cambodia for antenatal care this was 18% (poorest) and 71% (richest). Low coverage of interventions tended to show top inequity patterns whereas high coverage tended to show bottom inequity patterns. CONCLUSIONS: Reducing inequity is a necessary step in reducing neonatal deaths and also total child deaths. Intervention efforts need to begin to integrate approaches relevant to equity in programme design, implementation, monitoring and evaluation.     

Paediatric emergency and acute care in resource poor settings

Acute care of seriously ill children is a global public health issue, and there is much scope for improving quality of care in hospitals at all levels in many developing countries. We describe the current state of paediatric emergency and acute care in the least developed regions of low and middle income countries and identify gaps and requirements for improving quality. Approaches are needed which span the continuum of care: from triage and emergency treatment, the diagnostic process, identification of co‐morbidities, treatment, monitoring and supportive care, discharge planning and follow‐up. Improvements require support and training for health workers and quality processes. Effective training is that which is ongoing, combining good technical training in under‐graduate courses and continuing professional development. Quality processes combine evidence‐based guidelines, essential medicines, appropriate technology, appropriate financing of services, standards and assessment tools and training resources. While initial emergency treatment is based on common clinical syndromes, early differentiation is required for specific treatment, and this can usually be carried out clinically without expensive tests. While global strategies are important, it is what happens locally that makes a difference and is too often neglected. In rural areas in the poorest countries in the world, public doctors and nurses who provide emergency and acute care for children are revered by their communities and demonstrate daily that much can be carried out with little.     

Improving the delivery room setting in developing countries: the opinion of local health caregivers

OBJECTIVE: Neonatal mortality has remained steady or increased in many developing countries. A pragmatic approach to the organization of the delivery room setting, where a large part of neonatal deaths occurs, could detect the priorities for potential ameliorative interventions. We evaluated the local health caregivers' opinions regarding the priority areas for improving the hospital delivery room setting in developing countries. METHODS: Twenty-eight participants to a World Health Organization (WHO) workshop were asked to fill out an anonymous, written questionnaire regarding the priorities that could significantly improve their hospital delivery room setting. RESULTS: The three most important interventions for improving the delivery room setting were classified as following: education of all staff in newborn care (28%), optimize doctor-nurse/patient ratio (15%), equipment (14%), maternal-antenatal care (13%), role and responsibilities (8%), salary (8%), neonatal intensive care unit facilities (6%), availability of a specialized team for neonatal resuscitation (5%) and improve the building (3%). CONCLUSION: Education of health staff in newborn care, personnel organization and equipment availability are valued as high priorities by local health caregivers for improving the delivery room setting in developing countries. The opinion of operators involved in maternal and neonatal health may contribute to better design interventions in setting with limited resources.     

Child and adolescent mental disorders: the magnitude of the problem across the globe

Objective: Describe objectively the global gaps in policy, data gathering capacity, and resources to develop and implement services to support child mental health. Methods: Report on the World health Organization (WHO) child and adolescent mental health resources Atlas project. The Atlas project utilized key informants and was supplemented by studies that focused on policy. This report also draws on current epidemiological studies to provide a context for understanding the magnitude of the clinical problem. Results: Current global epidemiological data consistently reports that up to 20% of children and adolescents suffer from a disabling mental illness; that suicide is the third leading cause of death among adolescents; and that up to 50% of all adult mental disorders have their onset in adolescence. While epidemiological data appears relatively uniform globally, the same is not true for policy and resources for care. The gaps in resources for child mental health can be categorized as follows: economic, manpower, training, services and policy. Key findings from the Atlas project include: lack of program development in low income countries; lack of any policy in low income countries and absent specific comprehensive policy in both low and high income countries; lack of data gathering capacity including that for country‐level epidemiology and services outcomes; failure to provide social services in low income countries; lack of a continuum of care; and universal barriers to access. Further, the Atlas findings underscored the need for a critical analysis of the ‘burden of disease’ as it relates to the context of child and adolescent mental disorders, and the importance of defining the degree of ‘impairment’ of specific disorders in different cultures. Conclusions: The recent finding of substantial gaps in resources for child mental health underscores the need for enhanced data gathering, refinement of the economic argument for care, and need for innovative training approaches.     

Treated prevalence of and mental health services received by children and adolescents in 42 low-and-middle-income countries

Background: Little is known about the treated prevalence and services received by children and adolescents in low‐ and middle‐income countries (LAMICs). The purpose of this study is to describe the characteristics and capacity of mental health services for children and adolescents in 42 LAMICs. Methods: The World Health Organization Assessment Instrument for Mental Health Systems (WHO‐AIMS), a 155‐indicator instrument developed to assess key components of mental health service systems, was used to describe mental health services in 13 low, 24 lower‐middle, and 5 upper‐middle‐income countries. Child and adolescent service indicators used in the analysis were drawn from Domains 2 (mental health services), 4 (human resources), and 5 (links with other sectors) of the WHO‐AIMS instrument. Results: The median one‐year treated prevalence for children and adolescents is 159 per 100,000 population compared to a treated prevalence of 664 per 100,000 for the adult population. Children and adolescents make up 12% of the patient population in mental health outpatient facilities and less than 6% in all other types of mental health facilities. Less than 1% of beds in inpatient facilities are reserved for children and adolescents. Training provided for mental health professionals on child and adolescent mental health is minimal, with less than 1% receiving refresher training. Most countries (76%) organize educational campaigns on child and adolescent mental health. Conclusions: Mental health services for children and adolescents in low‐ and middle‐income countries are extremely scarce and greatly limit access to appropriate care. Scaling up of services resources will be necessary in order to meet the objectives of the WHO Mental Health Gap Action (mhGAP) program which identifies increased services for the treatment of child mental disorders as a priority.     

Development and technical basis of simplified guidelines for emergency triage assessment and treatment in developing countries. WHO Integrated Management of Childhood Illness (IMCI) Referral Care Project

Simplified guidelines for the emergency care of children have been developed to improve the triage and rapid initiation of appropriate emergency treatments for children presenting to hospitals in developing countries. The guidelines are part of the effort to improve referral level paediatric care within the World Health Organisation/Unicef strategy integrated management of childhood illness (IMCI), based on evidence of significant deficiencies in triage and emergency care. Existing emergency guidelines have been modified according to resource limitations and significant differences in the epidemiology of severe paediatric illness and preventable death in developing countries with raised infant and child mortality rates. In these settings, it is important to address the emergency management of diarrhoea with severe dehydration, severe malaria, severe malnutrition, and severe bacterial pneumonia, and to focus attention on sick infants younger than 2 months of age. The triage assessment relies on a few clinical signs, which can be readily taught so that it can be used by health workers with limited clinical background. The assessment has been designed so that it can be carried out quickly if negative, making it functional for triaging children in queues.     

Development and technical basis of simplified guidelines for emergency triage assessment and treatment in developing countries. WHO Integrated Management of Childhood Illness (IMCI) Referral Care Project.

Simplified guidelines for the emergency care of children have been developed to improve the triage and rapid initiation of appropriate emergency treatments for children presenting to hospitals in developing countries. The guidelines are part of the effort to improve referral level paediatric care within the World Health Organisation/Unicef strategy integrated management of childhood illness (IMCI), based on evidence of significant deficiencies in triage and emergency care. Existing emergency guidelines have been modified according to resource limitations and significant differences in the epidemiology of severe paediatric illness and preventable death in developing countries with raised infant and child mortality rates. In these settings, it is important to address the emergency management of diarrhoea with severe dehydration, severe malaria, severe malnutrition, and severe bacterial pneumonia, and to focus attention on sick infants younger than 2 months of age. The triage assessment relies on a few clinical signs, which can be readily taught so that it can be used by health workers with limited clinical background. The assessment has been designed so that it can be carried out quickly if negative, making it functional for triaging children in queues.     

Midwifery training to improve ante- and perinatal health in low- and middle-income countries of the former Soviet Union

Whether in the community or in the hospital, high-quality midwifery care is the preferable model of care for mothers and babies at the first level of care. Countries with professional midwifery care within a supportive system have the best outcomes for mother and babies. The low- and middle-income countries of the former Soviet Union report some of the highest maternal mortality and neonatal mortality in the European region, yet childbirth occurs in institutions with 'skilled attendants' (96-100%). Specific characteristics of maternal and neonatal care in countries of the former Soviet Union include over-medicalization, inappropriate use of technology, unnecessary hospitalizations, and ineffective and/or harmful interventions. This article highlights two midwifery trainings developed specifically to change the maternal and newborn care practices in countries of the former Soviet Union: the Family Centred Maternity Care Training of Trainers and the World Health Organization Essential Antenatal, Perinatal and Postpartum Care Training.     

Foreign aid, international organizations, and the world's children

Recent improvement in child mortality has taken place in all regions of the world. In developing countries, major remaining causes are neonatal problems, diarrheal diseases, vaccine-preventable diseases, and respiratory diseases. Foreign aid has come in many forms, among them individual persons, nongovernmental organizations, national governments, and international agencies. Governmental involvement in health activities abroad can advance foreign policy interests as well as help protect a country's citizens against existing and potential disease foci. Intergovernmental health agencies, regional and worldwide, have been in existence only in this century; the World Health Organization is barely 50 years old and suffers from US delinquency in paying its dues. Child labor has health aspects in industrialized as well as in developing countries. The United Nations Convention on the Rights of the Child has significant implications for health. Despite broad support, including that of the American Academy of Pediatrics, the United States has not ratified the convention, the only nation in the world beside Somalia not to do so.     

World Health Organization infant and young child feeding indicators and their associations with child anthropometry: a synthesis of recent findings

As the World Health Organization (WHO) infant and young child feeding (IYCF) indicators are increasingly adopted, a comparison of country‐specific analyses of the indicators' associations with child growth is needed to examine the consistency of these relationships across contexts and to assess the strengths and potential limitations of the indicators. This study aims to determine cross‐country patterns of associations of each of these indicators with child stunting, wasting, height‐for‐age z‐score (HAZ) and weight‐for‐height z‐score (WHZ). Eight studies using recent Demographic and Health Surveys data from a total of nine countries in sub‐Saharan Africa (nine), Asia (three) and the Caribbean (one) were identified. The WHO indicators showed mixed associations with child anthropometric indicators across countries. Breastfeeding indicators demonstrated negative associations with HAZ, while indicators of diet diversity and overall diet quality were positively associated with HAZ in Bangladesh, Ethiopia, India and Zambia (P < 0.05). These same complementary feeding indicators did not show consistent relationships with child stunting. Exclusive breastfeeding under 6 months of age was associated with greater WHZ in Bangladesh and Zambia (P < 0.05), although CF indicators did not show strong associations with WHZ or wasting. The lack of sensitivity and specificity of many of the IYCF indicators may contribute to the inconsistent associations observed. The WHO indicators are clearly valuable tools for broadly assessing the quality of child diets and for monitoring population trends in IYCF practices over time. However, additional measures of dietary quality and quantity may be necessary to understand how specific IYCF behaviours relate to child growth faltering.