Editorial Hospital care for children in developing countries: getting the evidence where it matters

Abstract

Medical knowledge is in constant flux: what is done routinely today is considered obsolete tomorrow. In the 1980, children presenting with viral croup to major university hospitals in Germany were treated with cold water nebulisation of the room in the attempt to create a cold, moist atmosphere which would make it easier for the children to breathe, and steroids were despised. Nowadays, the role of steroids is firmly established in the treatment of croup (Russell et al. 2004), and there is little, if any, evidence for the use of cold water nebulisation (Moore & Little 2006). Guidelines only reflect the knowledge of the day, and need to be regularly updated. The WHO Department of Child and Adolescent Health and Development and its predecessors, the ARI and diarrhoeal diseases control programmes, have a long history of developing evidence-based guidelines for clinical conditions affecting children in developing countries, such as pneumonia, neonatal sepsis and diarrhoea. The use of fast breathing as a clinical sign to detect pneumonia was suggested by workers in Papua New Guinea (Shann et al. 1984), and systematic research in other countries led to its adoption as the main sign to base the diagnosis of pneumonia on. Similarly, original guidelines used for identifying sick newborns that require hospital care were refined and simplified in further research (Young Infants Clinical Signs Study Group 2008). Documenting this evidence in a systematic way has become an integral part of guideline development. The quality of care provided in first level hospitals in developing countries has a major impact on the health and lives of millions of children admitted with severe disease each year. Throughout the world, care in these small district hospitals is provided by nurses, paramedical workers and non-specialist doctors. While child survival initiatives have largely focused on community interventions and primary care, large proportions of hospital funding and resources are allocated to tertiary institutions. As a result, most critically ill children are cared for where resources are inadequate, support from central agencies is lacking, there is poor access to information, there is little ongoing professional development or staff training and staff morale is invariably low (Nolan et al. 2001). Formative research on the quality of hospital care in seven countries found as one of the major problems the lack of treatment guidelines in small hospitals. This led to the development of the manual ‘Management of the child with a serious infection or severe malnutrition’, published in 2000 (WHO 2000). The book filled a gap and was much appreciated. However, a survey performed by WHO after publication on useful features and possible improvements of this book brought up several suggestions which led to the development of the ‘Pocket book of hospital care for children’ as the successor of the previous manual (WHO 2005). Apart from several expansions, such as a larger section on neonatal problems, the inclusion of surgical conditions and of HIV, the prominent feature is its pocket size and sturdy binding and cover. This made the pocket book an instantaneous success. David Morley considered it to be one of two essential publications for the district hospital, and made it available through the TALC dissemination network. There have been substantial reductions in case fatality rates where such hospital guidelines have been introduced and when they are accompanied by training, audit or other quality improvement measures. Implementation of guidelines for the management of severe malnutrition (Ahmed et al. 1999; Ashworth et al. 2004), oxygen delivery (Duke et al. 2000a) and neonatal care (Duke et al. 2000b) have reduced case fatality rates in hospitals in several developing countries. Emergency triage and treatment approaches, which are included in the WHO guidelines, are effectively used by nurses to identify and manage seriously ill children in busy outpatient departments in developing countries (Tamburlini et al. 1999; Molyneux 2001). Tropical Medicine and International Health doi:10.1111/j.1365-3156.2009.02390.x