Aims To determine the impact of a single ‘training of trainers’ ETAT (Emergency triage, assessment and treatment) paediatric resuscitation training programme on clinical practice of participating healthcare workers in Malawi. Methods Training was based on the WHO ETAT programme. Participants, senior healthcare workers working directly with children, completed a 4-day course including local ETAT implementation planning workshop. Impact on participant knowledge was assessed by pre and post-course test scores. Clinical practice impact was based on structured interview and retrospective case reporting at 6 months. Service impact was assessed after 6 months by site visits and hospital reports. Results 79 participants (47 nursing staff, 27 clinical officers, 3 medical assistants, 2 doctors) from 25 hospitals in 18 Malawian healthcare districts were trained. Pre and post-course knowledge tests (n=79) showed improvement in both individual and overall scores (overall mean score pre: 10.27 post: 12.48 p=<0.001). At 6 month follow-up 17 hospitals were visited and 20 made progress reports. Contact was lost with 5 hospitals. Around 25% of participants had left paediatric or health services. 6 month post-course knowledge test (n=32) showed retained improvement compared to pre-course scores (mean 6 month score: 11.81, p=0.001). 26 participants completed a structured interview at 6 months. All attributed positive changes in clinical practice to the course. 41 specific case histories of children's lives saved attributed to skills not used prior to the course were reported. ‘Life-saving’ skills included intra-osseous access (30 cases), bag-valve mask ventilation (7 cases) and anti-convulsant protocols (4 cases). 20 hospitals reported impact on service. 3 hospitals had introduced triage, 14 made improvements to existing triage systems. 8 hospitals had established a specific clinical area for resuscitation of children. 11 hospitals had obtained funding for participants to train colleagues: a further 272 healthcare workers had been trained in triage skills. Conclusions Logistical difficulties, resource limitation and high staff turnover were barriers to both local implementation of ETAT and assessment at follow-up. Training programmes and ‘real-life’ implementation need to be continuously supported to sustain improvement. Despite this there was evidence of knowledge gained and retained, and most importantly of positive impact on outcome for individual children. True impact may be underestimated.
Introduction: Acute convulsions in children are a common emergency worldwide. Benzodiazepines are the recommended first line treatment. Intravenous lorazepam is inexpensive, long acting and the first line drug in resource-rich settings. However, comparable efficacy by other routes of administration is unknown. We wished to compare the efficacy of lorazepam by the buccal, intranasal or intravenous route in the treatment of acute seizures in Malawian children. Methods:A prospective, open-label, randomised, non-inferiority trial was performed in children aged 2 months to 14 years presenting to the Queen Elizabeth Central Hospital in Blantyre, Malawi with acute seizures lasting longer than 5 min. Children were randomly assigned to receive lorazepam, 0.1 mg/kg, by the buccal, intranasal or intravenous route. The primary endpoint was seizure cessation within 10 min of drug administration. Results: There were 761 seizures analysed, with 252 patients in the buccal, 245 in the intranasal and 264 in the intravenous groups. Intravenous lorazepam stopped seizures within 10 min in 83%, intranasal lorazepam in 57% (RR 2.46, CI 1.82-3.34), and the buccal route in 46% (RR 3.14, CI 2.35-4.20; p = 0.001) of children. There were no significant cardio-respiratory events and no difference in mortality or neurological deficits. The study was halted after an interim analysis showed that the primary endpoint had exceeded the protocol-stopping rule. Conclusions: Intravenous lorazepam effectively treats most childhood seizures in this setting. Intranasal and buccal routes are less effective but may be useful in prehospital care or when intravenous access cannot be obtained. Further studies comparing intranasal lorazepam to other benzodiazepines, or alternative doses by a nonintravenous route are warranted.Introduction: dans le monde entier, les convulsions aigues constituent une urgence fre´quente. Il est recommande´d'utiliser des benzodiaze´pines en traitement de premie`re intention. Le loraze´pam administre´par voie intraveineuse est peu couˆteux, a une action prolonge´e, et constitue le traitement de premie`re intention dans les re´gions riches en ressources. L'efficacite´comparable de ce traitement par d'autres voies d'administration est cependant inconnue. Nous souhaitions comparer l'efficacite´du loraze´pam par voie orale, intranasale ou intraveineuse dans le traitement des attaques aigue¨s chez les enfants au Malawi. Me´thodes: Une e´tude prospective, ouverte, randomise´e et de non infe´riorite´a e´te´re´alise´e sur des enfants aˆge´s de deux mois a`14 ans se pre´sentant a`l'hoˆpital central Queen Elizabeth a`Blantyre, au Malawi, souffrant d'attaques aigue¨s de plus de cinq minutes. Les enfants e´taient re´partis de manie`re ale´atoire pour se voir administrer 0.1 mg/kg de loraze´pam par voie orale, intranasale ou intraveineuse. Le point final primaire e´tait l'interruption de l'attaque dans les 10 min suivant l'administration du me´dicament. Re´sultats: 761 attaques ont e´te´analyse´es, dont 252 patients dans le groupe d'administr...
In many settings, HIV infected children are looked after with limited access to CD4 cell count or viral load. The decision to initiate antiretroviral therapy (ART) is made clinically, based on the WHO paediatric staging criteria, which were revised in 2006. Results of using new and old criteria were compared. Of 694 children, 626 (90.2%) fulfilled criteria to start ART when applying the new WHO staging guidelines, whereas 330 (47.6%) children were eligible for ART when using the old WHO criteria. This signifies a marked rise in the number of paediatric patients qualifying for ART on clinical grounds.
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