Response to: Twenty-three thousand unnecessary deaths every day: What are you doing about it?

To the Editor: No ethical justification exists for providing intensive care to children in developed countries while denying it to children in poor countries. In addition, educated families in developing countries reasonably demand that their children have access to intensive care(1). In writing our statement on the Global agenda of The World Federation of Pediatric Intensive and Critical Care societies (2), one of our intentions was to stimulate discussion and debate regarding the appropriate role of the Federation and its members. Thus, we are delighted at the thoughtful and provocative response from Frank Shann and Trevor Duke (3), all the more so, because of the distinguished contribution that they have made to both pediatric critical care and international child health. We fully concur with many of the important points made in their statement. Recent reviews have highlighted the fact that as much as 65% of child deaths could be prevented today by the implementation of current knowledge within achievable budgets (even in the poorest countries), and without the introduction of intensive care (4). It is true that removal of trade barriers could improve substantially the economic potential of many developing countries and an increase in international aid would potentially increase the resources available to combat childhood deaths and poverty. Personal involvement of Federation members in humanitarian projects can only contribute positively. However, implementation of these projects requires careful planning and should be based on real rather than preconceived needs. We are, therefore, concerned about problems with the implementation of aid projects and the apparent pitfalls with some international aid as lucidly addressed by William Easterly and Dambisa Moyo (5, 6). It is important to note that we do not share their definition of critical care (endotracheal intubation or mechanical ventilation), and we have used a far wider definition: “the treatment of the child with a life-threatening illness or injury in its broadest sense, without regard for the location and including prehospital and emergency and intensive care.” Thus, we would see critical care for children as including all the interventions, such as early antibiotic therapy for neonatal infections (7), increased availability of oxygen monitoring and therapy for children with pneumonia (8–11), improved care for sick children at district hospitals (12–16), improved structure and organization of acute care services for children (17, 18), development of triage and management systems (19–21), and innovative training programs in prehospital trauma care (22–27). Many, if not all, of these interventions affect the care of children with life-threatening or potentially life-threatening illness or injury, and are applicable and affordable in even the poorest of countries. Certainly, we would see ourselves as a Federation that is open to all health workers with interests in these areas, and we would help to facilitate and support that work. The points about preventive services are well taken but we must grapple with both the dilemmas that many of our members face on a daily basis, and the needs of those children who could benefit from intensive care today. What about a child victim of a road accident who is in need of hospital care and transport? What about a child who had a snake bite and who could be saved with antivenom and a day or two of mechanical ventilation? Should they have to wait until the under-5 mortality is <30? We cannot overlook the fact that many critically ill children can be saved and their quality of life can be preserved if we can provide adequate and timely services now. We also cannot overlook the complexity of situations, for example, those that exist in countries like India today. Most of our members are involved in intensive care services, and so we need to focus on what people with skills and interests in intensive care can offer in their professional capacities to the world of sick children; however, this should not be done in isolation or at the exclusion of others. Even if we then agree to a narrower definition of critical care, and we accept the statement that “in countries with an under-5 mortality <20 to 30 per 1000, the Society clearly has a responsibility to foster the expert provision of intubation and ventilation,” major challenges still face our community. As the world moves toward 2015 and the target dates for the millennium development goals, it is exciting to note that increasing numbers of countries across the world are moving to the point where under-5 mortality is <20 per 1000. A review of data from Gapminder (28) shows that, although only a handful of countries had under-5 mortality <30 per 1000 in the 1960s, by 2005, nearly half had under-5 mortality <30 per 1000. Thus, the potential and appropriate need for pediatric intensive and critical care is enormous, and growing. The recent series of reviews on emergency care (29, 30), critical care (31–33), and pediatric critical care (34, 35) have highlighted the interest in and desperate need for development of critical care for both adults and children across the world. Many intensive care units across the developing world have relatively poor outcomes and there is a significant need to focus on improvement of those outcomes within the available resources in those settings. The development of critical care across the world forces us to focus on management of different conditions, such as dengue (36) and malaria (37, 38) which were previously confined to well-defined areas. Global changes in weather and travel are likely to affect the distribution of many illnesses across the world, and even the developed nations may be needing research and training on the management of diseases previously largely confined to developing countries (39). We will also need to approach different ethical issues in neonatal and pediatric critical care: whereas developing countries focus on issues, such as “who should be admitted” (40–42), and “is it appropriate to give this care to this child in the context of his or her family circumstances” (43), some developed countries have to focus on overtreatment in the pediatric intensive care unit (44), and futile or inappropriate care (45). Issues of infection control in the pediatric intensive care unit are increasingly concerning in both developed countries and the developing world (40, 46). Recognition of the need for pediatric and congenital heart surgery in the developing world is growing (47–49) and this too will bring a demand for increased intensive care services. It is therefore essential to move from the occasional humanitarian missions to developing countries to the development of stable and effective cardiac services in developing countries. As critical care services across the world develop and expand, we believe that the federation will have to respond to the need for: Focused and appropriate research to improve the quality of outcomes of pediatric intensive care within the resources that are available; Training and development of significant numbers of pediatric intensive care workers across the world; Integration of critical and intensive care to ensure the appropriate management of sick or injured children from time of first presentation to healthcare services; Support for healthcare workers who are faced with the ongoing challenges of caring for critically ill and injured children; Programs to empower parents in the care of their child, decision-making processes, and assurance of parent’s and family’s well-being. The challenge is to find the appropriate role that we need to (and can effectively) play in decreasing both unnecessary death and suffering for children. We feel that this document, although imperfect, is a good starting point and we hope that it will stimulate more discussion to guide the agenda of the federation for years to come. The authors have not disclosed any potential conflicts of interest. Andrew Argent, MD WFPICCS President, School of Child and Adolescent Health, University of Cape Town, Red Cross War Memorial Children’s Hospital, Cape Town, South Africa; Niranjan Kissoon, MD, CPE WFPICCS President Elect, University of British Columbia, British Columbia Children’s Hospital, Vancouver, British Columbia, Canada; Denis Devictor, MD, PhD WFPICCS Secretary, Hopital Bicetre, Kremlin Bicetre, France; Maureen A. Madden, RN, MSN WFPICCS Vice-President Nursing Affairs, UMDNJ - Robert Wood Johnson Medical School, New Brunswick, NJ; Sunit Singhi, MD, PhD WFPICCS Executive Member, Advanced Pediatrics Centre, Postgraduate Institute of Medical Education and Research, Chandigarh, India; Edwin van der Voort, MD WFPICCS Past President, Erasmus MC - Sophia Children’s Hospital, Rotterdam, Netherlands; Jos M. Latour, RN, MSN WFPICCS Treasurer, Erasmus MC - Sophia Children’s Hospital, Rotterdam, Netherlands

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