WHO EMRO - CHILD AND ADOLESCENT HEALTH

Notably, more than 90% of the deaths from injuries occur in low- and middle-income countries[1]. The silence drama of injuries is in that for each death thousand survivors will have to live with permanent disabilities[1].. This painful truth is experienced even more by children as they grow into adolescents and adults. Injury-related mortality rates in children below 5 years old in the EMR were estimated to be 97.1 in boys and 109.1 in girls per 100 000 population in 2000: these rates were above the world average rates for this age group[1].^. Top

Together with falls and drowning, burns and poisoning are major contributors to the burden of injury in children. Globally, children under five years of age account for about 15% of both fire-related and unintentional poisoning-related deaths[1]^{^.}Children under‑five -both boys and girls- in the Eastern Mediterranean Region pay the highest price among all age groups (except for the elderly) for fire-related burn mortality, with rates of 11.4 and 9.1 per 100 000, respectively, in 2000[1]. These rates are way above world averages. Also, mortality rates related to accidental poisoning in children under-5 per 100 000 population are virtually the highest among all age groups in the Eastern Mediterranean Region (except for the elderly). When looking at global contribution by age to total number of DALYs (disability-adjusted life years ) lost to fire-related burns, over 50% of them are among children less than 15 years old. Yet, these data do not include other types of burns that are most common in young children (e.g. scalds) and therefore largely underestimate the real extent of the problem. Children under-5 contribute to about 23% of DALYs lost globally to poisoning¹. Exposures occur much more frequently in children below 5 years old than older children, because of their curiosity to explore the environment and tendency to put things in their mouth, their ignoring of the risks, and play patterns. Top

Given this background and the substantial, potential impact of preventive interventions in reducing injury-related deaths and burden in children, the Child and Adolescent Health and Development unit (CAH) of this Regional Office has started work aiming at addressing two among the most common injuries in children, namely burns and poisoning. The first phase relates to the development of standard clinical protocols for the outpatient management of children with burns and poisoning seen at primary health care facilities, to improve the capacity at this level. The next phase will address the issue more broadly and at its roots, to involve families and communities in making environments safer for children and thus protecting their health. Top

1. Derivation of the clinical decision rules from expert opinion. A draft algorithm has been prepared by the the Child and Adolescent Health and Development unit (CAH) of this Regional Office and is being reviewed by burn experts. An electronic discussion group was established on 12 June 2004 for this purpose. To date, technical input has been received from the following burn centres:

A review paper was also commissioned to review the technical basis for the algorithm and identify knowledge gaps which require further research. The review paper was prepared by Professor Roy Kimble, University of Queensland, Department of Paediatrics and Child Health, and Clinical Director of Burns, The Stuart Pegg Paediatric Burns Centre, Royal Children's Hospital, Herston, Australia.

2. Testing and validation of the algorithm and provider performance analysis. Training materials will be developed to train PHC providers on the use of the algorithm for pilot-testing. A library of cases with burns under 5 years old has also been prepared to develop a photo booklet as a reference training material. Then, to maximise the limited resources available and to reduce the time required for the process, three issues will be addressed at the same time: 1. Use of the algorithm by the trained PHC providers in a Burn Centre; 2. Analysis of their performance against a gold standard to validate the algorithm; and 3. Collection of data during this process, to address specific, unresolved issues. Further prospective validation in other clinical settings will depend on the identification of suitable sites and availability of funds. top

The draft algorithm has been revised based on the initial comments that have been received from burn centres experts, a number of controversial issues have been identified and a review paper has been prepared. Work to develop visual aids and a library of burn cases with different degrees of burns has been completed and a first draft prepared; the draft materials are expected to be reviewed in 2007.

1. Derivation of the clinical decision rules from a prospective study at a Poison Control Centre (Poison Control Centre of Ain Shams University Hospitals, Cairo, Egypt). The data, collected in 2004 and 2005, have enabled to construct a list of potential predictors of severity of selected, common poisonings in children below 5 years old, identifying the predictors which are most powerful and practical to use under field conditions. Based on the analysis of these data, draft clinical algorithms (clinical decision rules) have been prepared.

2: Validation of the algorithm in at least another clinical setting and provider performance analysis (“broad validation”). When additional funds become available and another suitable site is identified, the clinical algorithm will be validated prospectively in another setting in another country with a different prevalence and spectrum of the poisoning conditions. Health providers will be trained in the use of the algorithm, and their performance and conclusions will be compared with a gold standard under research conditions. This step will provide further evidence to the technical soundness of the guidelines in multiple settings (evidence of reproducible accuracy) and when used by those providers for whom these have been designed. top

Among acute poisonings in children, accidental exposure to hydrocarbons—especially kerosene—and caustic agents is frequently reported. Organophosphates and carbamates are among the most frequently used insecticides, and children under-5 account for a large proportion of acute, accidental poisonings from these agents. Children are more vulnerable to the effects of pesticides and they may absorb relatively more chemical due to their larger surface area to body weight ratio. Thus, a smaller dose is required to cause symptoms in children than in adults. Children often need to be admitted and managed as inpatients. Research work therefore is focusing on poisoning from hydrocarbons, organophosphates, carbamates, and caustic agents. Although believed to occur frequently in the home also in developing countries, cases of accidental poisoning from iron and paracetamol rarely seem to reach the tertiary health facility level where reliable research could be conducted: prospective studies would then require a long duration. Also, management guidelines already exist and no IMCI research work is currently planned in this area by the Regional Office. Other causes of poisoning may be considered at a later stage. top

Enrolment of 256 children with exposure to hydrocarbons and 95 children with exposure to organophosphates and carbamates in two prospective studies on clinical predictors of severity of accidental poisoning from hydrocarbons and from organophosphates and carbamates, respectively, in children below five years old was completed in 2005. The studies were carried out at the Poison Control Centre of Ain Shams University Hospitals, Cairo, Egypt. The results of the hydrocarbon study “A clinical decision rule for triage of children under 5 years of age with hydrocarbon (kerosene) aspiration in developing countries”, by the WHO EMRO Pediatric Hydrocarbon Study Group, were presented at the North American Congress of Clinical Toxicology, Orlando, Florida, September 2005, appear in abstract form in Clin Toxicol 2005; 43:634 and have been published in Clinical Toxicology, Volume 46, Issue 3 March 2008, pages 222 – 229. The results of the organophosphate / carbamate study "A clinical decision aid for triage of children under five years of age with organophosphate or carbamate insecticide exposure in developing countries”, by the WHO EMRO Pediatric Insecticide Study Group, presented at the North American Congress of Clinical Toxicology, San Francisco, California, October 2006, appear in abstract form in Clinical Toxicology 2006, 44:716 , and have been published in the Annals of Emergency Medicine, Volume 52, Issue 6, December 2008, pages 617-622. A summary of the main results of both studies was presented also at the Regional IMCI coordinators' meeting, Amman, Jordan, 2007, and is described in the related report. A study to validate the algorithms in another setting is being planned. top

[1] The injury chartbook: A graphical overview of the global burden of injuries, World Health Organization, Geneva, 2002 http://whqlibdoc.who.int/publications/924156220X.pdf