Correction: Weight estimation for children aged 6 to 59 months in limited-resource settings: A proposal for a tape using height and mid-upper arm circumference.

[This corrects the article DOI: 10.1371/journal.pone.0197769.].

Weight estimation for children aged 6 to 59 months in limited-resource settings: A proposal for a tape using height and mid-upper arm circumference.

IMPORTANCE: A simple, reliable tool for rapid estimation of weight in children would be useful in limited-resource settings where current weight estimation tools are not reliable, nearly all global under-five mortality occurs, severe acute malnutrition is a significant contributor in approximately one-third of under-five mortality, and a weight scale may not be immediately available to healthcare professionals including first-response providers. OBJECTIVE: To test the accuracy and precision of an existing weight estimation tool based on patient height and mid-upper arm circumference (MUAC) in children between six months and five years of age in low-to-middle income countries. DESIGN: Data were collected in 2,434 nutritional surveys during 1992-2017 using a modified Expanded Program of Immunization two-stage cluster design. SETTING: Locations in 51 low-to-middle income countries with high prevalence of acute and chronic malnutrition. PARTICIPANTS: Of 1,848,979 children enrolled in the surveys, a total of 1,800,322 children met inclusion criteria (age 6-59 months; weight ≤ 25 kg; MUAC 80-200 mm) and exclusion criterion (bilateral pitting edema and biologically implausible measurements based on WHO flagging criteria). EXPOSURES: Weight was estimated by a regression procedure using database height and MUAC. MAIN OUTCOMES AND MEASURES: Mean percentage difference between true and estimated weight (MPD), proportion of estimates accurate to within ± 10% and ± 20% of true weight (PW10 and PW20), weighted Kappa statistic, and Bland-Altman bias (bias) were reported as measures of tool accuracy. Standard deviation (SD) of the MPD and Bland-Altman 95% limits of agreement (LOA) were reported as measures of tool precision. RESULTS: The height model fitted for MUAC classes was accurate and precise. MPD was +0.67% (SD = 9.95%); PW10/PW20 were 68.31% (95% CI 68.24%, 68.38%)/94.73% (95% CI 94.69%, 94.76%); and bias (LOA) were +0.06 kg (-1.97 kg; +2.10 kg). For MUAC < 115 mm, PW10/PW20 were 63.91% (95% CI 63.42%, 64.40%)/90.72% (95% CI 90.42%, 91.01%); and bias (LOA) were +0.14 kg (-1.29 kg; +1.56 kg). For 115 mm ≤ MUAC < 125 mm, PW10/PW20 were 76.27% (95% CI 76.03%, 76.51%)/96.36% (95% CI 96.25%, 96.46%); and bias (LOA) were +0.06 kg (-1.20 kg; +1.33 kg). For MUAC > 125 mm, PW10/PW20 were 69.93% (95% CI 69.86%, 70.00%)/95.27% (95% CI 95.24%, 95.30%); and bias (LOA) were +0.05 kg (-2.04 kg; +2.13 kg). CONCLUSIONS AND RELEVANCE: An updated model estimating weight from height and MUAC in a large database of children aged 6 to 59 months across a wide range of low-to-middle income countries with high prevalence of acute and chronic malnutrition was confirmed to be accurate and precise. A height-based weight estimation tape stratified according to MUAC classes is proposed for children aged 6-59 months in limited-resource settings.

Teaching Pediatric Life Support in Limited-Resource Settings: Contextualized Management Guidelines.

Of the estimated 6.3 million global annual deaths in children younger than the age of 5 years, nearly all (99%) occur in low- to middle-income countries (LMIC). Existing management guidelines for children with emergency conditions as taught in a variety of current pediatric life support courses are mostly applicable to high-income countries with a different disease range and full resources compared with LMIC. A revised curriculum with evidence-based application to limited-resource settings would expand their potential for reducing pediatric mortality worldwide. This review provides a supplemental curriculum of standards for selected pediatric emergency conditions with attention to the context of disease range and level-specific resources in LMIC. During training sessions, contextualized management guidelines create the framework for realistic and fruitful case simulations.

Weight Estimation Tool for Children Aged 6 to 59 Months in Limited-Resource Settings.

IMPORTANCE: A simple, reliable anthropometric tool for rapid estimation of weight in children would be useful in limited-resource settings where current weight estimation tools are not uniformly reliable, nearly all global under-five mortality occurs, severe acute malnutrition is a significant contributor in approximately one-third of under-five mortality, and a weight scale may not be immediately available in emergencies to first-response providers. OBJECTIVE: To determine the accuracy and precision of mid-upper arm circumference (MUAC) and height as weight estimation tools in children under five years of age in low-to-middle income countries. DESIGN: This was a retrospective observational study. Data were collected in 560 nutritional surveys during 1992-2006 using a modified Expanded Program of Immunization two-stage cluster sample design. SETTING: Locations with high prevalence of acute and chronic malnutrition. PARTICIPANTS: A total of 453,990 children met inclusion criteria (age 6-59 months; weight ≤ 25 kg; MUAC 80-200 mm) and exclusion criteria (bilateral pitting edema; biologically implausible weight-for-height z-score (WHZ), weight-for-age z-score (WAZ), and height-for-age z-score (HAZ) values). EXPOSURES: Weight was estimated using Broselow Tape, Hong Kong formula, and database MUAC alone, height alone, and height and MUAC combined. MAIN OUTCOMES AND MEASURES: Mean percentage difference between true and estimated weight, proportion of estimates accurate to within ± 25% and ± 10% of true weight, weighted Kappa statistic, and Bland-Altman bias were reported as measures of tool accuracy. Standard deviation of mean percentage difference and Bland-Altman 95% limits of agreement were reported as measures of tool precision. RESULTS: Database height was a more accurate and precise predictor of weight compared to Broselow Tape 2007 [B], Broselow Tape 2011 [A], and MUAC. Mean percentage difference between true and estimated weight was +0.49% (SD = 10.33%); proportion of estimates accurate to within ± 25% of true weight was 97.36% (95% CI 97.40%, 97.46%); and Bland-Altman bias and 95% limits of agreement were 0.05 kg and (-2.15 kg; 2.24 kg). The height model fitted for MUAC classes was accurate and precise. For MUAC < 115 mm, the proportion of estimates accurate to within ± 25% of true weight was 97.15% (95% CI 96.90%, 97.42%) and the Bland-Altman bias and 95% limits of agreement were 0.08 kg and (-1.21 kg; 1.37 kg). For MUAC between 115 and 125 mm, the proportion of estimates accurate to within ± 25% of true weight was 98.93% (95% CI 98.82%, 99.03%) and Bland-Altman bias and 95% limits of agreement were 0.05 kg and (-1.15 kg; 1.24 kg). For MUAC > 125 mm, the proportion of estimates accurate to within ± 25% of true weight was 98.33% (95% CI 98.29%, 98.37%) and Bland-Altman bias and 95% limits of agreement were 0.05 kg and (-2.08 kg; 2.19 kg). CONCLUSIONS AND RELEVANCE: Models estimating weight from height alone and height with MUAC class in children aged 6-59 months in a database from low-to-middle income countries were more accurate and precise than previous weight estimation tools. A height-based weight estimation tape stratified according to MUAC classes is proposed for children aged 6-59 months in limited-resource settings.

Impact of contextualized pediatric resuscitation training on pediatric healthcare providers in Botswana.

BACKGROUND: Worldwide, 6.6 million children die each year, partly due to a failure to recognize and treat acutely ill children. Programs that improve provider recognition and treatment initiation may improve child survival. OBJECTIVES: Describe provider characteristics and hospital resources during a contextualized pediatric resuscitation training program in Botswana and determine if training impacts provider knowledge retention. DESIGN/METHODS: The American Heart Association's Pediatric Emergency Assessment Recognition and Stabilization (PEARS) course was contextualized to Botswana resources and practice guidelines in this observational study. A cohort of facility-based nurses (FBN) was assessed prior to and 1-month following training. Survey tools assessed provider characteristics, cognitive knowledge and confidence and hospital pediatric resources. Data analysis utilized Fisher's exact, Chi-square, Wilcoxon rank-sum and linear regression where appropriate. RESULTS: 61 healthcare providers (89% FBNs, 11% physicians) successfully completed PEARS training. Referral facilities had more pediatric specific equipment and high-flow oxygen. Median frequency of pediatric resuscitation was higher in referral compared to district level FBN's (5 [3,10] vs. 2 [1,3] p=0.007). While 50% of FBN's had previous resuscitation training, none was pediatric specific. Median provider confidence improved significantly after training (3.8/5 vs. 4.7/5, p<0.001), as did knowledge of correct management of acute pneumonia and diarrhea (44% vs. 100%, p<0.001, 6% vs. 67%, p<0.001, respectively). CONCLUSION: FBN's in Botswana report frequent resuscitation of ill children but low baseline training. Provider knowledge for recognition and initial treatment of respiratory distress and shock is low. Contextualized training significantly increased FBN provider confidence and knowledge retention 1-month after training.

Global paediatric advanced life support: improving child survival in limited-resource settings.

Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries. The leading causes of mortality in children younger than 5 years worldwide, pneumonia and diarrhoeal illness, account for 1·396 and 0·801 million annual deaths, respectively. Although important advances in prevention are being made, advanced life support management in children in developing countries is often incomplete because of limited resources. Existing advanced life support management guidelines for children in limited-resource settings are mainly empirical, rather than evidence-based, written for the hospital setting, not standardised with a systematic approach to patient assessment and categorisation of illness, and taught in current paediatric advanced life support training courses from the perspective of full-resource settings. In this Review, we focus on extension of higher quality emergency and critical care services to children in developing countries. When integrated into existing primary care programmes, simple inexpensive advanced life support management can improve child survival worldwide.

New opportunity to improve pediatric emergency preparedness: pediatric emergency assessment, recognition, and stabilization course.

The ideal first response to a life-threatening pediatric emergency includes early recognition of the emergency, activation of the appropriate emergency response system, performance of basic life support (cardiopulmonary resuscitation/automated external defibrillator treatment), and initiation of advanced life support, but the extent of resuscitation training among health care providers likely to be first at the side of a critically ill or injured child is often deficient. In the past, resuscitation courses beyond basic life support focused on training advanced providers. The Pediatric Emergency Assessment, Recognition, and Stabilization course was developed by the American Heart Association to target a broad range of health care providers who are likely to be first at the side of a child requiring resuscitation. It is hoped that training of health care providers through the Pediatric Emergency Assessment, Recognition, and Stabilization course will translate into early recognition of life-threatening pediatric emergencies and greater resuscitation success, but results will depend on the availability of instruction and the maintenance of skills.

Comparison of levalbuterol and racemic albuterol combined with ipratropium bromide in acute pediatric asthma: a randomized controlled trial.

Our study compared levalbuterol (LEV) to the combination of racemic albuterol (RAC) and ipratropium bromide (IB) in 140 patients aged 6-18 years presenting to a tertiary hospital Emergency Department with acute asthma and a peak expired flow rate (PEF)<80% predicted. Patients were randomized to: LEV (

This issue: Managing emergencies part 2.

Pediatric toxicologic exposures are common, and the primary care pediatric practitioner must be prepared to handle emergencies related to poisoning and overdose in children and adolescents. Fortunately, many poisonings in children are unintentional, preventable, and benign. For both simple and complex cases, help is available to medical professionals 24/7 from multiple sources, including an improved toxic exposure database, new research, the network of Certified Specialists in Poison Information at our nation's regional poison control centers, and backup medical and clinical toxicologists. The US system of AAPCC-certified poison control centers has been appropriately labeled "a national safety net" serving the public and medical practitioners in the management of pediatric toxicologic exposures. Increased funding to this system will be critical to update its services for the future, including preparation to detect the increasing threat of new public health emergencies such as chemical and biological terrorist attacks.

Physiologic anterior subluxation: case report of occurrence at C5 to C6 and C6 to C7 spinal levels.

Physiologic anterior subluxation is a phenomenon that is common to the upper pediatric cervical spine and characterized by the normal forward displacement of one cervical vertebra relative to the subjacent one. Physiologic anterior subluxation can be seen in children in the setting of trauma, when it must be distinguished from pathologic subluxation. Physiologic anterior subluxation has not been reported at lower cervical spinal levels (C 5 to C 6 or C 6 to C 7 ). This is a report of physiologic anterior subluxation at C 5 to C 6 and C 6 to C 7 spinal levels distinguished from pathologic subluxation in a 9-year-old child evaluated in the acute setting after cervical spine injury.

Role of oblique radiographs in blunt pediatric cervical spine injury.

OBJECTIVE: To determine the usefulness of oblique cervical spine radiography (OCSR) in the management of children who have sustained blunt cervical spine injury, particularly if OCSR is abnormal when no acute abnormalities are shown on standard cervical spine radiography (SCSR). METHODS: We carried out a blinded radiographic review of 109 patients younger than 16 years evaluated at an academic pediatric trauma center and a community hospital between July 1990 and December 1997. All patients had SCSR (anteroposterior/lateral views) and OCSR performed for a trauma-related event within 7 days of injury. RESULTS: In 105 patients (96.3%), radiographic impression after review of SCSR and OCSR did not differ from that after SCSR review alone (95% confidence interval 90.9%, 99.0%). Radiographic impression was revised after OCSR review in 4 patients, all with equivocal findings on SCSR, to normal in three patients and abnormal in one patient (subluxation). Of 78 patients without acute abnormalities on SCSR, no patient had acute abnormalities on OCSR (95% CI, 0-3.8%). CONCLUSIONS: In our series of 109 children who underwent acute radiographic evaluation of blunt cervical spine trauma, oblique views were unlikely to be abnormal if no acute abnormalities were evident on standard anteroposterior and lateral radiographs. Although few patients are likely to benefit from the addition of these views on a routine basis, a useful role for oblique cervical spine radiographs in detecting cervical spine injury in children cannot be excluded based on the results of this study.