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Others have made the point convincingly that Millennium Development Goal 4, a reinvigorated commitment to reduce child mortality by two-thirds before 2015, could be achieved if existing interventions were implemented [...]

Pneumonia is the single commonest cause of death Pin children under five years old, accounting for 2 million out of 10 million childhood deaths worldwide [1]. Severe pneumonia is an [...]

ABSTRACT Background Clinical trials of interventions designed to prevent severe falciparum malaria in children require a clear endpoint. The internationally accepted definition of severe malaria is sensitive, and appropriate for [...]

Author(s): Mike English 1,2,*, Grace Irimu 2,3, Ambrose Agweyu 2, David Gathara 2, Jacquie Oliwa 2, Philip Ayieko 2, Fred Were 4, Chris Paton 1, Sean Tunis 5, Christopher B. [...]

Summary Points * Antibiotics that are well absorbed after oral administration are available, and the best current evidence suggests they are safe and effective for many conditions. * Belief in the superiority of intravenous antibiotics is widespread among health professionals and patients, but it is not supported by good evidence. Expanding the evidence base will provide patients and clinicians with further reassurance in specific situations, but reasons for the belief in the strength of intravenous therapy also need to be understood and addressed. * Trials expanding the evidence base might follow noninferiority designs, based on the precedent of widespread intravenous use. For many indications, the theoretical reasons for preferring intravenous therapy are not strong, and the risks of intravenous therapy are well established. It would be more logical for many indications to regard oral antibiotics as the default position and require trial designs to test the superiority of intravenous therapy. * Clarity regarding the harms and benefits of intravenous antibiotics is needed. There is potential to change global clinical practice for the better, reducing health care costs and minimizing harm to patients., Intravenous Antibiotic Use Antibiotics given intravenously are commonly used in both high- and low-income countries. Available evidence from well-established antibiotic stewardship programmes in high-income settings suggests this is frequently unnecessary [...]

Background to the debate: Current guidelines recommend that all fever episodes in African children be treated presumptively with antimalarial drugs. But declining malarial transmission in parts of sub-Saharan Africa, declining proportions of fevers due to malaria, and the availability of rapid diagnostic tests mean it may be time for this policy to change. This debate examines whether enough evidence exists to support abandoning presumptive treatment and whether African health systems have the capacity to support a shift toward laboratory-confirmed rather than presumptive diagnosis and treatment of malaria in children under five., In this Viewpoint, Mike English and colleagues argue against abandoning presumptive treatment for under-fives. Blaise Genton and colleagues present the opposing Viewpoint in a related article: D'Acremont V, Lengeler C, [...]

Background: To improve care for children in district hospitals in Kenya, a multifaceted approach employing guidelines, training, supervision, feedback, and facilitation was developed, for brevity called the Emergency Triage and Treatment plus (ETAT+) strategy. We assessed the cost effectiveness of the ETAT+ strategy, in Kenyan hospitals. Further, we estimate the costs of scaling up the intervention to Kenya nationally and potential cost effectiveness at scale. Methods and Findings: Our cost-effectiveness analysis from the provider's perspective used data from a previously reported cluster randomized trial comparing the full ETAT+ strategy (n = 4 hospitals) with a partial intervention (n = 4 hospitals). Effectiveness was measured using 14 process measures that capture improvements in quality of care; their average was used as a summary measure of quality. Economic costs of the development and implementation of the intervention were determined (2009 US$). Incremental cost-effectiveness ratios were defined as the incremental cost per percentage improvement in (average) quality of care. Probabilistic sensitivity analysis was used to assess uncertainty. The cost per child admission was US$50.74 (95% CI 49.26-67.06) in intervention hospitals compared to US$31.1 (95% CI 30.6747.18) in control hospitals. Each percentage improvement in average quality of care cost an additional US$0.79 (95% CI 0.19-2.31) per admitted child. The estimated annual cost of nationally scaling up the full intervention was US$3.6 million, approximately 0.6% of the annual child health budget in Kenya. A 'what-if' analysis assuming conservative reductions in mortality suggests the incremental cost per disability adjusted life year (DALY) averted by scaling up would vary between US$39.8 and US$398.3. Conclusion: Improving quality of care at scale nationally with the full ETAT+ strategy may be affordable for low income countries such as Kenya. Resultant plausible reductions in hospital mortality suggest the intervention could be cost-effective when compared to incremental cost-effectiveness ratios of other priority child health interventions. Please see later in the article for the Editors' Summary., Introduction An estimated 7.6 million children die globally every year before the age of five [1]. 99% of these deaths occur in developing countries; 50% in sub-Saharan Africa [2]. Most [...]

Background: In developing countries referral of severely ill children from primary care to district hospitals is common, but hospital care is often of poor quality. However, strategies to change multiple paediatric care practices in rural hospitals have rarely been evaluated. Methods and Findings: This cluster randomized trial was conducted in eight rural Kenyan district hospitals, four of which were randomly assigned to a full intervention aimed at improving quality of clinical care (evidence-based guidelines, training, job aides, local facilitation, supervision, and face-to-face feedback; n = 4) and the remaining four to control intervention (guidelines, didactic training, job aides, and written feedback; n = 4). Prespecified structure, process, and outcome indicators were measured at baseline and during three and five 6-monthly surveys in control and intervention hospitals, respectively. Primary outcomes were process of care measures, assessed at 18 months postbaseline. In both groups performance improved from baseline. Completion of admission assessment tasks was higher in intervention sites at 18 months (mean = 0.94 versus 0.65, adjusted difference 0.54 [95% confidence interval 0.05-0.29]). Uptake of guideline recommended therapeutic practices was also higher within intervention hospitals: adoption of once daily gentamicin (89.2% versus 74.4%;17.1% [8.04%-26.1%]);loading dose quinine (91.9% versus 66.7%, 26.3% [-3.66% to 56.3%]);and adequate prescriptions of intravenous fluids for severe dehydration (67.2% versus 40.6%;29.9% [10.9%-48.9%]). The proportion of children receiving inappropriate doses of drugs in intervention hospitals was lower (quinine dose >40 mg/ kg/day;1.0% versus 7.5%;-6.5% [-12.9% to 0.20%]), and inadequate gentamicin dose (2.2% versus 9.0%;-6.8% [-11.9% to -1.6%]). Conclusions: Specific efforts are needed to improve hospital care in developing countries. A full, multifaceted intervention was associated with greater changes in practice spanning multiple, high mortality conditions in rural Kenyan hospitals than a partial intervention, providing one model for bridging the evidence to practice gap and improving admission care in similar settings. Trial registration: Current Controlled Trials ISRCTN42996612 Please see later in the article for the Editors' Summary., Introduction Common illnesses including pneumonia, malaria, and diarrhea remain major contributors to child mortality in low-income countries [1]. Hospital care of severe illnesses may help improve survival, and disease-specific clinical [...]

Mike English and colleagues argue that we do not have sufficient evidence and health system capacity to abandon presumptive antimalarial treatment in children with fever in sub-Saharan Africa, countering the argument of Blaise Genton and colleagues in a related paper. [ABSTRACT FROM AUTHOR]

Background: Pulse oximetry, a relatively inexpensive technology, has the potential to improve health outcomes by reducing incorrect diagnoses and supporting appropriate treatment decisions. There is evidence that in low- and middle-income countries, even when available, widespread uptake of pulse oximeters has not occurred, and little research has examined why. We sought to determine when and with which children pulse oximeters are used in Kenyan hospitals, how pulse oximeter use impacts treatment provision, and the barriers to pulse oximeter use.Methods and Findings: We analyzed admissions data recorded through Kenya's Clinical Information Network (CIN) between September 2013 and February 2016. We carried out multiple imputation and generated multivariable regression models in R. We also conducted interviews with 30 healthcare workers and staff from 14 Kenyan hospitals to examine pulse oximetry adoption. We adapted the Integrative Model of Behavioural Prediction to link the results from the multivariable regression analyses to the qualitative findings. We included 27,906 child admissions from 7 hospitals in the quantitative analyses. The median age of the children was 1 year, and 55% were male. Three-quarters had a fever, over half had a cough; other symptoms/signs were difficulty breathing (34%), difficulty feeding (34%), and indrawing (32%). The most common diagnoses were pneumonia, diarrhea, and malaria: 45%, 35%, and 28% of children, respectively, had these diagnoses. Half of the children obtained a pulse oximeter reading, and of these, 10% had an oxygen saturation level below 90%. Children were more likely to receive a pulse oximeter reading if they were not alert (odds ratio [OR]: 1.30, 95% confidence interval (CI): 1.09, 1.55, p = 0.003), had chest indrawing (OR: 1.28, 95% CI: 1.17, 1.40, p < 0.001), or a very high respiratory rate (OR: 1.27, 95% CI: 1.13, 1.43, p < 0.001), as were children admitted to certain hospitals, at later time periods, and when a Paediatric Admission Record (PAR) was used (OR PAR used compared with PAR not present: 2.41, 95% CI: 1.98, 2.94, p < 0.001). Children were more likely to be prescribed oxygen if a pulse oximeter reading was obtained (OR: 1.42, 95% CI:1.25, 1.62, p < 0.001) and if this reading was below 90% (OR: 3.29, 95% CI: 2.82, 3.84, p < 0.001). The interviews indicated that the main barriers to pulse oximeter use are inadequate supply, broken pulse oximeters, and insufficient training on how, when, and why to use pulse oximeters and interpret their results. According to the interviews, variation in pulse oximeter use between hospitals is because of differences in pulse oximeter availability and the leadership of senior doctors in advocating for pulse oximeter use, whereas variation within hospitals over time is due to repair delays. Pulse oximeter use increased over time, likely because of the CIN's feedback to hospitals. When pulse oximeters are used, they are sometimes used incorrectly and some healthcare workers lack confidence in readings that contradict clinical signs. The main limitations of the study are that children with high levels of missing data were not excluded, interview participants might not have been representative, and the interviews did not enable a detailed exploration of differences between counties or across senior management groups.Conclusions: There remain major challenges to implementing pulse oximetry-a cheap, decades old technology-into routine care in Kenya. Implementation requires efficient and transparent procurement and repair systems to ensure adequate availability. Periodic training, structured clinical records that include prompts, the promotion of pulse oximetry by senior doctors, and monitoring and feedback might also support pulse oximeter use. Our findings can inform strategies to support the use of pulse oximeters to guide prompt and effective treatment, in line with the Sustainable Development Goals. Without effective implementation, the potential benefits of pulse oximeters and possible hospital cost-savings by targeting oxygen therapy might not be realized. [ABSTRACT FROM AUTHOR]