In low resource-countries, the mortality of critically-ill children remains high. Severe pneumonia remains one of the leading causes of death. Malaria and intercurrent bacteraemia adversly affects survival in this setting. Low cost bubble continuous positive airway pressure (bCPAP) set-ups are used in some reference centres in sub-Saharan Africa. More evidence for use beyond the neonatal period is needed. We evaluated the role of bCPAP for the care of critically-ill children in Lilongwe, Malawi.This observational study was conducted between 26 February-15 April 2014, in a busy, urban paediatric unit with >20,000 admissions/year (in-hospital mortality ~ 3%). Modified oxygen concentrators or oxygen cylinders provided humidified bCPAP air/oxygen flow. The inclusion criteria was a convenience sample of non-neonates initiated on bCPAP at the discretion of a clinician. BCPAP failure was defined as; death during bCPAP treatment, within 48 h of bCPAP weaning, or escalation to intubation. Ethical approval was from the Malawi National Health-Sciences Research-Committee.116 children with symptoms of WHO defined very severe pneumonia (VSPNA) were included. Median age: 8 months. Median duration of bCPAP treatment: 2.5 days. Malaria rapid-tests were positive in 36 (31%) cases. 34 (29%) had severe anaemia (Hb <7.0 g/dL). 58 (50%) children had > 1 organ-failure (MOF). 23 (20%) children were HIV-positive/exposed. 24 (21%) were malnourished. The over-all survival was 74/116 (64%). 33/34 (97%) with signs of uncomplicated VSPNA survived and HIV infection/exposure did appear to affect survival in this group. Treatment failure rates rose with the presence of respiratory depression, MOF or signs of shock (delayed capillary refill time etc.)The higher survival rates among children with uncomplicated VSPNA indicates that bCPAP could be used in resource-limited, malaria-endemic settings with a high HIV prevalence. This is important to explore, as Malawi has been reported as doing well to reduce under 5 mortality. This success has been attributed to following and implementing new evidence based interventions and policies. The time may have come when critical care skills and technologies from developed settings can be used to benefit those suffering the inordinate burden of disease in the developing world.

Aims Globally, an estimated 0.8 million children under five die of diarrhoea annually. Clear, evidence-based clinical management protocols exist, but their successful implementation in resource-limited clinical settings remains challenging. This clinical audit aimed to evaluate the impact of a simple, novel integrated care pathway (ICP) on standards of assessment and management of children with acute diarrhoea in a rural hospial in Bangladesh, and to assess any cost implication for the family. The ICP includes a simple checklist of clinical symptoms and signs which allow the severity of dehydration to be accurately assessed, and integrates this with the relevant treatment algorithm.The impact of the new ICP was measured against the 4 endpoints listed in the results section. Methods Retrospective case notes study of admitted children (1 month to 12 years) with acute diarrhoea in 2012. Patient management was evaluated against hospital guidelines. As the ICP was implemented at the end of May 2012, the patients were split into two cohorts: A (pre-ICP) and B (post-ICP). 183 patients were included in total. Conclusion The implementation of the ICP in this clinical setting improved the quality of acute diarrhoea management.Rates of incorrect dehydration assessment fell by 25%, rates of evidence-based rehydration increased by 48% and rates of unnecessary IV fluid administration decreased by 33%. In addition, there was a 72% reduction in cost of fluids for the family. Aims Severe Acute Malnutrition (SAM) underlies some 500,000 young child deaths per year. For the first time, new (December 2013) World Health Organisation Guidelines recognise SAM in infants <6 months (u6m). Research in this group is however lacking: WHO assessed the quality of current evidence as 'VERY LOW' according to the GRADE framework (Grading of Recommendations Assessment, Development and Evaluation).In this study we aimed to address a key question highlighted by WHO: how best to identify high risk infants u6m. We did this by:-Comparing prevalence of infant SAM as defined by current weight-for-length (WFL)-based definitions with proposed new definitions based on mid-upper-arm circumference (MUAC).-Identifying risk factors for use in future clinical assessment tools. Methods A cross sectional prevalence survey conducted in two referral hospitals and three community health centres in Malawi. All infants u6m excluding twins attending for either medical attention or routine immunizations were measured and asked about potential malnutrition risk factors.Results From October 2013-January 2014 we measured 6,787 infants u6m. After data cleaning, we analysed a total of 5,717 infants u6m: 582 from hospitals; 5,135 from health centres.Defined by WFL <À3 z-scores, 1.6% (90) infants had SAM. Defined by MUAC <110mm, 3.9% (214) had SAM. By MUAC <115mm, an additional 3.5% (188) had SAM. However defined, prevalence was higher in the hospitals than in health centres (3.5% vs 1.4% by WFL; 4.5% vs 3.4% by MUAC).There were no male/female sex differences. Infants with low...

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