Identifying Targets for Improving Quality of Pediatric Emergency and Critical Care in Low-Resource Settings

Introduction: Nearly 6 million children and adolescents died worldwide in 2021, largely due to preventable causes and disproportionately in low- and middle-income countries (LMICs). To reduce child mortality in LMICs, targeted pediatric emergency and critical care (PECC) quality-of-care interventions are needed. Several knowledge gaps must be addressed to inform their design. Objectives: This thesis (1) describes the epidemiology of disease and outcomes of children 0–14 years presenting with acute illness to a District Headquarter (DHQ) hospital in Pakistan, (2) synthesizes the evidence for performance of pediatric mortality prognostic models developed and validated in LMICs, and (3) describes the global infrastructure for PECC in low-resource settings. Synthesis: In Chapter 3, we included 3850 children presenting to Sanghar DHQ hospital outpatient department and 1286 admitted children. Communicable diseases were the most common presenting diagnoses among outpatients and among inpatients 1–9 years. Non-communicable diseases and nutritional disorders were more common with increasing age. At 28 days from hospital admission, 50 children had died. Age <28 days was associated with increased odds of death (OR 4.39 [95% CI 2.4–8.26], p<0.001, reference age: 28 days-14 years). No sex differences in mortality risk were observed. Leading causes of death included neonatal sepsis/meningitis, neonatal encephalopathy, and lower respiratory tract infections. In Chapter 4, we identified seven prognostic models for hospital mortality validated in >1 cohort. The Lambarene Organ Dysfunction Score [0.85 (0.63–0.95)] and Signs of Inflammation in Children that Kill [0.85 (0.84–0.86)] had the highest summary C-statistics (95% CI). All models were at high risk of bias. In Chapter 5, we described infrastructure for PECC in 238 hospitals in 60 countries, predominantly in Latin America and Africa (N=161, 67.4%). Across 174 intensive care units (ICUs), there were statistically significant differences in the proportion of hospitals reporting consistent resource availability between World Bank country income groups. Resources with low availability in low- and lower-middle income countries included specialized staff, ICU equipment, diagnostic tests (imaging, microbiology, biochemistry), and commonly used drugs. Conclusion: This thesis addresses important knowledge gaps regarding the foundations for delivery of high-quality PECC to reduce child mortality from acute illness.

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