Background In low-income countries and those with a high prevalence of HIV, respiratory failure is a common cause of death in children. However, the role of non-invasive ventilation with bubble continuous positive airway pressure (bCPAP) in these patients is not well established. Methods A prospective observational study of bCPAP was undertaken between July and September 2012 in 77 Malawian children aged 1 week to 14 years with progressive acute respiratory failure despite oxygen and antimicrobial therapy. Results Forty-one (53%) patients survived following bCPAP treatment, and an HIV-uninfected single-organ disease subgroup demonstrated bCPAP success in 14 of 17 (82%). Compared with children aged ≥60 months, infants of 0–2 months had a 93% lower odds of bCPAP failure (odds ratio 0.07, 95% confidence interval 0.004–1.02, P = 0.05). Following commencement of bCPAP, respiratory physiology improved, the average respiratory rate decreased from 61 to 49 breaths/minute (P = 0.0006), and mean oxygen saturation increased from 92.1% to 96.1% (P = 0.02). Conclusions bCPAP was well accepted by caregivers and patients and can be feasibly implemented into a tertiary African hospital with high-risk patients and limited resources.

IntroductionIn low-resource countries, respiratory failure is associated with a high mortality risk among critically ill children. We evaluated the role of bubble continuous positive airway pressure (bCPAP) in the routine care of critically ill children in Lilongwe, Malawi.MethodsWe conducted an observational study between 26 February and 15 April 2014, in an urban paediatric unit with approximately 20 000 admissions/year (in-hospital mortality <5% approximately during this time period). Modified oxygen concentrators or oxygen cylinders provided humidified bCPAP air/oxygen flow. Children up to the age of 59 months with signs of severe respiratory dysfunction were recruited. Survival was defined as survival during the bCPAP-treatment and during a period of 48 hours following the end of the bCPAP-weaning process.Results117 children with signs of respiratory failure were included in this study and treated with bCPAP. Median age: 7 months. Malaria rapid diagnostic tests were positive in 25 (21%) cases, 15 (13%) had severe anaemia (Hb < 7.0 g/dL); 55 (47%) children had multiorgan failure (MOF); 22 (19%) children were HIV-infected/exposed. 28 (24%) were severely malnourished. Overall survival was 79/117 (68%); survival was 54/62 (87%) in children with very severe pneumonia (VSPNA) but without MOF. Among the 19 children with VSPNA (single-organ failure (SOF)) and negative HIV tests, all children survived. Survival rates were lower in children with MOF (including shock) (45%) as well as in children with severe malnutrition (36%) and proven HIV infection or exposure (45%).ConclusionDespite the limitations of this study, the good outcome of children with signs of severe respiratory dysfunction (SOF) suggests that it is feasible to use bCPAP in the hospital management of critically ill children in resource-limited settings. The role of bCPAP and other forms of non-invasive ventilatory support as a part of an improved care package for critically ill children with MOF at tertiary and district hospital level in low-resource countries needs further evaluation. Critically ill children with nutritional deficiencies and/or HIV infection/exposure need further study to determine bCPAP efficacy.

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.

60 parents from a NICU, postnatal ward and PICU were approached once through child's stay on the unit.91 HCPs (including consultants, trainees, fellows, nursing and allied health professionals) participated in an online survey in a PICU distributed by closed group network of emails. Results Results of the survey: NICU parents (n=30):HCPs' survey (n=91): How did you address parents? (Option of more than one answer selection) 'Mum/Dad': Some parents on NICU preferred to be called 'mum' or 'dad'. A parent felt that, 'between all the stress and constant worry, it was a reminder that they are still parents'.A foster carer appreciated use of 'mum/dad' for herself and her husband, as they felt that the staff were acknowledging that 'we see ourselves as mummy and daddy rather than simply carers'.When the HCPs were asked about barriers they faced in addressing parents by their names, they were worried that they would 'forget their names' or 'get their name wrong'. Conclusions It is surprising that parents often would like to be called Mum or Dad. Many also do not mind how they are addressed. However, some prefer to be called by their name especially in PICU.HCPs are often unsure what would be the correct way to address parents and worry about remembering their names.This study shows the importance of not making assumptions and ask parents how they would like to be addressed.HCPs may be helped by reminders such as cot cards or badges. However, it may also be polite to admit you do not remember a parent's name and ask them again.Whilst communicating to parents, it's important to remember 'The person behind a parent'.

BackgroundNeonatal mortality is high in low-resource settings. NeoTree is a digital intervention for neonatal healthcare professionals (HCPs) aiming to achieve data-driven quality improvement and improved neonatal survival in low-resource hospitals. Optimising usability with end-users could help digital health interventions succeed beyond pilot stages in low-resource settings. Usability is the quality of a user's experience when interacting with an intervention, encompassing their effectiveness, efficiency, and overall satisfaction.ObjectiveTo evaluate the usability and usage of NeoTree beta-app and conduct Agile usability-focused intervention development.MethodA real-world pilot of NeoTree beta-app was conducted over 6 months at Kamuzu Central Hospital neonatal unit, Malawi. Prior to deployment, think-aloud interviews were conducted to guide nurses through the app whilst voicing their thoughts aloud (n = 6). System Usability Scale (SUS) scores were collected before the implementation of NeoTree into usual clinical care and 6 months after implementation (n = 8 and 8). During the pilot, real-world user-feedback and user-data were gathered. Feedback notes were subjected to thematic analysis within an Agile “product backlog.” For usage, number of users, user-cadre, proportion of admissions/outcomes recorded digitally, and median app-completion times were calculated.ResultsTwelve overarching usability themes generated 57 app adjustments, 39 (68%) from think aloud analysis and 18 (32%) from the real-world testing. A total of 21 usability themes/issues with corresponding app features were produced and added to the app. Six themes relating to data collection included exhaustiveness of data schema, prevention of errors, ease of progression, efficiency of data entry using shortcuts, navigation of user interface (UI), and relevancy of content. Six themes relating to the clinical care included cohesion with ward process, embedded education, locally coherent language, adaptability of user-interface to available resources, and printout design to facilitate handover. SUS scores were above average (88.1 and 89.4 at 1 and 6 months, respectively). Ninety-three different HCPs of 5 cadres, recorded 1,323 admissions and 1,197 outcomes over 6 months. NeoTree achieved 100% digital coverage of sick neonates admitted. Median completion times were 16 and 8 min for admissions and outcomes, respectively.ConclusionsThis study demonstrates optimisation of a digital health app in a low-resource setting and could inform other similar usability studies apps in similar settings.