BackgroundMost childhood deaths globally are considered preventable through high-quality clinical care, which includes adherence to clinical care recommendations. Our objective was to describe adherence to World Health Organization recommendations for the management of leading causes of death among children.MethodsWe conducted a retrospective, descriptive study examining clinical data for children aged 1–59 months who were hospitalized and died in a Child Health and Mortality Prevention Surveillance (CHAMPS) catchment, December 2016–June 2021. Catchment areas included: Baliakandi and Faridpur, Bangladesh; Kersa, Haramaya, and Harar, Ethiopia; Kisumu and Siaya, Kenya; Bamako, Mali; Manhiça and Quelimane, Mozambique; Makeni, Sierra Leone; Soweto, South Africa. We reviewed medical records of those who died from lower respiratory tract infections, sepsis, malnutrition, malaria, and diarrheal diseases to determine the proportion who received recommended treatments and compared adherence by hospitalization duration.FindingsCHAMPS enrolled 460 hospitalized children who died from the leading causes (median age 12 months, 53.0% male). Median hospital admission was 31 h. There were 51.0% (n = 127/249) of children who died from lower respiratory tract infections received supplemental oxygen. Administration of intravenous fluids for sepsis (15.9%, n = 36/226) and supplemental feeds for malnutrition (14.0%, n = 18/129) were uncommon. There were 51.4% (n = 55/107) of those who died from malaria received antimalarials. Of the 80 children who died from diarrheal diseases, 76.2% received intravenous fluids. Those admitted for ≥24 h more commonly received antibiotics for lower respiratory tract infections and sepsis, supplemental feeds for malnutrition, and intravenous fluids for sepsis than those admitted <24 h.InterpretationProvision of recommended clinical care for leading causes of death among young children was suboptimal. Further studies are needed to understand the reasons for deficits in clinical care recommendation adherence.FundingBill & Melinda Gates Foundation. 

Provider adherence to clinical care recommendations for infants and children who died in seven low- and middle-income countries in the Child Health and Mortality Prevention Surveillance (CHAMPS) network

BACKGROUND Pediatric inpatient mortality rates are as high as 11% in parts of sub-Saharan Africa. Unscheduled clinic visits also burden children in sub-Saharan Africa. Our objective was to identify factors associated with hospital admissions and unscheduled clinic visits among Tanzanian children < 24 months of age. METHODS We conducted a secondary analysis of 2 trials conducted in Dar es Salaam, Tanzania. We performed univariate and Poisson multivariable regression analyses to identify factors associated with hospital admissions and unscheduled clinic visits. RESULTS Of 4784 children < 24 months of age, 293 (6.1%) were hospitalized at least once and 1308 (27.3%) had ≥ 1 unscheduled clinic visit. Infants and children who were exposed to but HIV-negative had increased risk of hospital admission [adjusted risk ratios (aRR): 3.67; 95% CI: 2.45-5.50; P < 0.001] compared with HIV-unexposed children. Those who were HIV-positive had even higher risk of hospital admission compared with those not exposed to HIV (aRR: 10.87; 95% CI: 7.01-16.89; P < 0.001). Birth weight and breast-feeding status were not associated with increased risk of hospital admission. Children with Apgar scores < 7 (aRR: 1.32; 95% CI: 1.03-1.69; P = 0.001), not exclusively breast-fed up to 6 months of age (aRR: 1.34; 95% CI: 1.12-1.60; P = 0.001), and who were HIV-exposed and HIV-negative (aRR: 2.35; 95% CI: 2.08-2.66; P < 0.001) or HIV-positive (aRR: 3.02; 95% CI: 2.52-3.61; P < 0.001) had higher risk of unscheduled clinic visits. CONCLUSIONS Exposure to HIV and being HIV-positive were associated with the greatest risk for hospital admission and unplanned clinic visits among infants and children in Tanzania. Targeting these vulnerable populations in interventional studies may reduce morbidity.

Identifying Infants and Young Children at Risk of Unplanned Hospital Admissions and Clinic Visits in Dar es Salaam, Tanzania.

To identify social and economic factors that correlate with virologic suppression (VS) in children and adolescents living with human immunodeficiency virus (CALHIV) after initiation of antiretroviral therapy (ART). This was a retrospective cohort study of patients under 20 years of age initiating ART at a single site in Lilongwe, Malawi between January 2016 and September 2018. Baseline clinical and socioeconomic variables were abstracted from the site’s electronic medical records and these were compared to documented VS. A total of 327 CALHIV were initiated on ART at this site during the study period, with a median age of 7.5 years; 47% were female. Of the 308 patients that fulfilled inclusion criteria, 109 (35%) had documented VS within 8 months of ART initiation. With multiple logistic regression, the only socioeconomic variable independently associated with VS was using a personal vehicle to travel to clinic visits (adjusted odds ratio [aOR] 2.80, 95% confidence interval [CI] 1.16–6.76) and this association was stronger in the subgroup of children under 5 years old (aOR 4.52, 95% CI 1.24–16.4). Compared to those aged 5 to 19 years, a significantly higher proportion of subjects under 5 years old died during the 8 months after ART initiation (1.6% vs 9.8%, p = 0.001). Mode of transport to clinic was independently associated with documented VS for this cohort of CALHIV. Ongoing research to further identify key social factors associated VS for CALHIV will be important for achieving the third of the UNAIDS’ 90–90–90 targets.

Socioeconomic factors associated with virologic suppression in children and adolescents living with HIV in Lilongwe, Malawi

Severe acute malnutrition (SAM) is a major cause of childhood mortality in resource-limited settings. The relationship between clinical factors and adherence to the ‘WHO 10 Steps’ and mortality in ...

Risk factors for mortality and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi.

During the era of the Millennium Development Goals, under 5 mortality rates decreased significantly worldwide; however, reductions were not equally distributed. Children in sub-Saharan Africa still account for more than 50% of the world’s annual childhood deaths among children under 5 years of age. Understanding upstream risk factors for mortality among children may reduce the large burden of childhood mortality in sub-Saharan Africa. Our objective was to identify risk factors for mortality among infants and children in Tanzania. We conducted a secondary analysis of data pooled from two randomized-controlled micronutrient supplementation trials. A total of 4787 infants were enrolled in the two trials (n = 2387 HIV-exposed and n = 2400 HIV-unexposed). Predictors of mortality were assessed using unadjusted and adjusted hazard ratios (aHRs). There were 307 total deaths, 262 (11%) among children who were HIV-exposed and 45 (2%) among children who were HIV-unexposed (P < 0.001). The most common cause of death was respiratory diseases (n = 109, 35.5%). Causes of death did not significantly differ between HIV-exposed and HIV-unexposed children. In adjusted regression analyses, children with birth weight <2500 g (aHR 1.75, 95% CI 1.21–2.54), Apgar score of ≤7 at 5 min (aHR 2.16, 95% CI 1.29–3.62), or who were HIV-exposed but not infected (aHR 3.35, 95% CI 2.12–5.28) or HIV-infected (aHR 27.56, 95% CI 17.43–43.58) had greater risk of mortality. Infection with HIV, low birthweight, or low Apgar scores were associated with higher mortality risk. Early identification and modification of determinants of mortality among infants and children may be the first step to reducing such deaths.

/pdf/risk-factors-for-mortality-among-tanzanian-infants-and-1xwwmsem6n.pdf

Risk factors for mortality among Tanzanian infants and children.

BACKGROUND Human immunodeficiency virus (HIV) contributes to nearly 20% of all deaths in children under five years of age in Malawi. Expanded coverage of antiretroviral therapy has allowed children to access treatment on an outpatient basis. Little is known about characteristics of the final outpatient encounter prior to mortality in the outpatient setting. METHODS This retrospective cohort study assessed clinical factors associated with mortality among HIV-exposed infants and HIV-infected children less than 18 years of age at the Baylor College of Medicine Abbott Fund Children's Center of Excellence in Lilongwe, Malawi. We compared clinical indicators documented from the final outpatient encounter for patients who died in the outpatient setting versus those who were alive after their penultimate clinical encounter. RESULTS Of the 8,546 patients who were attended to over a 10-year period at the Baylor Center of Excellence, 851 had died (10%). Of children who died, 392 (46%) were directly admitted to the hospital after their last clinical encounter and died as inpatients. Of the remaining 459 who died as outpatients after their last visit, 53.5% had a World Health Organization (WHO) stage IV condition at their last visit, and 25% had a WHO stage III condition. Multivariate regression analysis demonstrated that poor nutritional status, female gender, shorter time as a patient, more clinical encounters in the prior month, if last visit was an unscheduled sick visit, and if the patient had lost weight since their prior visit independently predicted increased mortality in the outpatient setting after the final clinical encounter. CONCLUSION Clinical indicators may assist in identifying children with HIV who have increased risk of mortality in the outpatient setting. Recognizing these indicators may aid in identifying HIV-infected children who require a higher level of care or closer follow-up.

/pdf/an-analysis-of-the-last-clinical-encounter-before-outpatient-ozzci8x8do.pdf

An Analysis of the Last Clinical Encounter before Outpatient Mortality among Children with HIV Infection and Exposure in Lilongwe, Malawi.

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An Analysis of the Last Clinical Encounter before Outpatient Mortality among Children with HIV Infection and Exposure in Lilongwe, Malawi.