Journal Article > CommentaryFull Text
Lancet Child Adolesc Health. 5 October 2018; Volume 2 (Issue 12); DOI:10.1016/S2352-4642(18)30284-0
Umphrey L, Brown AL, Hiffler L, Lafferty N, Garcia DM, et al.
Lancet Child Adolesc Health. 5 October 2018; Volume 2 (Issue 12); DOI:10.1016/S2352-4642(18)30284-0
Conference Material > Abstract
Omar MF, Kashifa Z, Ghalib MK, Deslandes D, Morton N
MSF Scientific Days International 2019: Innovation. 10 May 2019
INTRODUCTION
Palliative care improves the quality of life of patients, and their families, facing problems associated with life-threatening illness, through the prevention and relief of suffering. Most children needing palliative care at the end of life are neonates residing in low- and middle-income countries; around 68% have perinatal conditions, and nearly 10% have congenital anomalies. MSF operates maternity services within Dasht-e-Barchi hospital, Kabul, Afghanistan, where over one thousand deliveries take place each month. The intermediate-level neonatal unit receives babies with extremely low birth weight, extreme prematurity, congenital anomalies and other conditions such as severe birth asphyxia. For many of these babies, intensive curative therapy is deemed not in the baby's best interests and providing appropriate comfort care is required. We describe our efforts to implement palliative care in this setting.
METHODS
Steps taken towards implementation of palliative care within the neonatal unit initially involved discussions with key stakeholders, including the project clinical staff, the Ministry of Health and community leaders, to identify needs and local barriers. Following this, sensitization and training of staff was carried out to improve understanding of palliative care. Finally, we developed a palliative care framework, involving tools for clinical management, as well as guidance for decision-making and communication, and the implementation of a palliative care committee.
ETHICS
This innovation project did not involve human participants or their data; the MSF Ethics Framework for Innovation was used to help identify and mitigate potential harms.
RESULTS
Discussions with key stakeholders, including individuals based within the Ministry of Health, community leaders, and clinical staff, helped identify contextual barriers to implementing palliative care, including religious beliefs and the lack of an existing medical and legal framework. Some staff initially described resistance, partly due to their lack of experience or training in palliative care, and the absence of formal policies around palliative care in Afghanistan. We carried out training for nursing and medical staff, focusing on core concepts and technical skills. We developed a communication framework, to help deliver clear and consistent information to caregivers, addressing the need for understanding improvements in quantity and quality of the baby’s life. To further enhance communication and collaboration, a palliative care committee was established, including nursing, medical and managerial staff. This committee meets regularly to discuss palliative care issues, as well as also holding ad-hoc meetings to support clinical decision-making and caregiver counselling.
CONCLUSIONS
The implementation of neonatal palliative care requires involvement of key stakeholders to overcome potential barriers and to develop a clear framework. The palliative care committee we developed provides a support system to help facilitate consistent decision-making, and a collaborative multi-disciplinary approach for clinical care. While there are ongoing challenges in such a context, our experience shows that it is possible to implement context-specific and family-centered palliative care.
CONFLICTS OF INTEREST
None declared.
Palliative care improves the quality of life of patients, and their families, facing problems associated with life-threatening illness, through the prevention and relief of suffering. Most children needing palliative care at the end of life are neonates residing in low- and middle-income countries; around 68% have perinatal conditions, and nearly 10% have congenital anomalies. MSF operates maternity services within Dasht-e-Barchi hospital, Kabul, Afghanistan, where over one thousand deliveries take place each month. The intermediate-level neonatal unit receives babies with extremely low birth weight, extreme prematurity, congenital anomalies and other conditions such as severe birth asphyxia. For many of these babies, intensive curative therapy is deemed not in the baby's best interests and providing appropriate comfort care is required. We describe our efforts to implement palliative care in this setting.
METHODS
Steps taken towards implementation of palliative care within the neonatal unit initially involved discussions with key stakeholders, including the project clinical staff, the Ministry of Health and community leaders, to identify needs and local barriers. Following this, sensitization and training of staff was carried out to improve understanding of palliative care. Finally, we developed a palliative care framework, involving tools for clinical management, as well as guidance for decision-making and communication, and the implementation of a palliative care committee.
ETHICS
This innovation project did not involve human participants or their data; the MSF Ethics Framework for Innovation was used to help identify and mitigate potential harms.
RESULTS
Discussions with key stakeholders, including individuals based within the Ministry of Health, community leaders, and clinical staff, helped identify contextual barriers to implementing palliative care, including religious beliefs and the lack of an existing medical and legal framework. Some staff initially described resistance, partly due to their lack of experience or training in palliative care, and the absence of formal policies around palliative care in Afghanistan. We carried out training for nursing and medical staff, focusing on core concepts and technical skills. We developed a communication framework, to help deliver clear and consistent information to caregivers, addressing the need for understanding improvements in quantity and quality of the baby’s life. To further enhance communication and collaboration, a palliative care committee was established, including nursing, medical and managerial staff. This committee meets regularly to discuss palliative care issues, as well as also holding ad-hoc meetings to support clinical decision-making and caregiver counselling.
CONCLUSIONS
The implementation of neonatal palliative care requires involvement of key stakeholders to overcome potential barriers and to develop a clear framework. The palliative care committee we developed provides a support system to help facilitate consistent decision-making, and a collaborative multi-disciplinary approach for clinical care. While there are ongoing challenges in such a context, our experience shows that it is possible to implement context-specific and family-centered palliative care.
CONFLICTS OF INTEREST
None declared.
Journal Article > ResearchFull Text
Pediatr Res. 29 January 2020; Volume 88 (Issue 4); DOI:10.1038/s41390-020-0783-z
Haidar MK, Morton N, Roederer T, Mayronne S, Bawo L, et al.
Pediatr Res. 29 January 2020; Volume 88 (Issue 4); DOI:10.1038/s41390-020-0783-z
BACKGROUND:
The prognostic significance of hyperlactatemia in young children with liver injury suspected to be attributed to repeated supratherapeutic doses of acetaminophen remain understudied.
METHODS:
We conducted a retrospective medical chart review including children aged <5 years admitted with hepatocellular injury. The study was conducted in Bardnesville Junction Hospital operated by Médecins Sans Frontières in Monrovia, Liberia.
RESULTS:
We analyzed 95 children with liver injury in whom a blood lactate measurement on admission was available. Eighty children (84%) were aged <2 years; 49 children (52%) died during hospitalization. The median acetaminophen concentration on admission was 20 mg/L with 60 (70%) children presenting concentrations exceeding 10 mg/L. Median lactate was significantly higher in children who died (10.7 mmol/L; interquartile range (IQR): 8.5-15.7) than those who survived (6.1 mmol/L; IQR: 4.1-8.5), P value < 0.001). The optimal threshold obtained was 7.2 mmol/L with a sensitivity of 84% and specificity 70% (area under curve = 0.80). The previously established thresholds of 3.5 and 4 mmol/L lactate had very low specificity identifying non-survival in children included in this study.
CONCLUSION:
In this setting, young children with ALF possibly attributed to acetaminophen toxicity were unlikely to survive if the venous blood lactate concentration exceeded 7.2 mmol/L.
The prognostic significance of hyperlactatemia in young children with liver injury suspected to be attributed to repeated supratherapeutic doses of acetaminophen remain understudied.
METHODS:
We conducted a retrospective medical chart review including children aged <5 years admitted with hepatocellular injury. The study was conducted in Bardnesville Junction Hospital operated by Médecins Sans Frontières in Monrovia, Liberia.
RESULTS:
We analyzed 95 children with liver injury in whom a blood lactate measurement on admission was available. Eighty children (84%) were aged <2 years; 49 children (52%) died during hospitalization. The median acetaminophen concentration on admission was 20 mg/L with 60 (70%) children presenting concentrations exceeding 10 mg/L. Median lactate was significantly higher in children who died (10.7 mmol/L; interquartile range (IQR): 8.5-15.7) than those who survived (6.1 mmol/L; IQR: 4.1-8.5), P value < 0.001). The optimal threshold obtained was 7.2 mmol/L with a sensitivity of 84% and specificity 70% (area under curve = 0.80). The previously established thresholds of 3.5 and 4 mmol/L lactate had very low specificity identifying non-survival in children included in this study.
CONCLUSION:
In this setting, young children with ALF possibly attributed to acetaminophen toxicity were unlikely to survive if the venous blood lactate concentration exceeded 7.2 mmol/L.
Journal Article > LetterFull Text
Lancet Global Health. 1 December 2017; Volume 5 (Issue 12); e1188.; DOI:10.1016/S2214-109X(17)30417-5
Haidar MK, Farhat JB, Saim M, Morton N, Defourny I
Lancet Global Health. 1 December 2017; Volume 5 (Issue 12); e1188.; DOI:10.1016/S2214-109X(17)30417-5
Journal Article > ReviewFull Text
MMWR Morb Mortal Wkly Rep. 27 September 2021; Volume 5 (Issue 1); e001156.; DOI:10.1136/bmjpo-2021-001156
Janet S, Russell N, Morton N, Martinez D, Tamannai M, et al.
MMWR Morb Mortal Wkly Rep. 27 September 2021; Volume 5 (Issue 1); e001156.; DOI:10.1136/bmjpo-2021-001156
Around the world, one in four children live in a country affected by conflict, political insecurity and disaster. Healthcare in humanitarian and fragile settings is challenging and complex to provide, particularly for children. Furthermore, there is a distinct lack of medical literature from humanitarian settings to guide best practice in such specific and resource-limited contexts. In light of these challenges, Médecins Sans Frontières (MSF), an international medical humanitarian organisation, created the MSF Paediatric Days with the aim of uniting field staff, policymakers and academia to exchange ideas, align efforts, inspire and share frontline research and experiences to advance humanitarian paediatric and neonatal care. This 2-day event takes place regularly since 2016. The fourth edition of the MSF Paediatric Days in April 2021 covered five main topics: essential newborn care, community-based models of care, paediatric tuberculosis, antimicrobial resistance in neonatal and paediatric care and the collateral damage of COVID-19 on child health. In addition, eight virtual stands from internal MSF initiatives and external MSF collaborating partners were available, and 49 poster communications and five inspiring short talks referred to as 'PAEDTalks' were presented. In conclusion, the MSF Paediatric Days serves as a unique forum to advance knowledge on humanitarian paediatrics and creates opportunities for individual and collective learning, as well as networking spaces for interaction and exchange of ideas.
Conference Material > Video
Morton N
MSF Scientific Days International 2019: Innovation. 10 May 2019
Journal Article > ResearchFull Text
BMC Pediatr. 30 March 2020; DOI:10.1186/s12887-020-2008-3.
Haidar MK, Vogt F, Takahashi K, Henaff F, Umphrey L, et al.
BMC Pediatr. 30 March 2020; DOI:10.1186/s12887-020-2008-3.
Background-
A cluster of cases of unexplained multi-organ failure was reported in children at Bardnesville Junction Hospital (BJH), Monrovia, Liberia. Prior to admission, children’s caregivers reported antibiotic, antimalarial, paracetamol, and traditional treatment consumption. Since we could not exclude a toxic aetiology, and paracetamol overdose in particular, we implemented prospective syndromic surveillance to better define the clinical characteristics of these children. To investigate risk factors, we performed a case–control study.
Methods-
The investigation was conducted in BJH between July 2015 and January 2016. In-hospital syndromic surveillance identified children with at least two of the following symptoms: respiratory distress with normal pulse oximetry while breathing ambient air; altered consciousness; hypoglycaemia; jaundice; and hepatomegaly. After refining the case definition to better reflect potential risk factors for hepatic dysfunction, we selected cases identified from syndromic surveillance for a matched case–control study. Cases were matched with in-hospital and community-based controls by age, sex, month of illness/admission, severity (in-hospital), and proximity of residence (community).
Results-
Between July and December 2015, 77 case-patients were captured by syndromic surveillance; 68 (88%) were under three years old and 35 (46%) died during hospitalisation. Of these 77, 30 children met our case definition and were matched with 53 hospital and 48 community controls. Paracetamol was the most frequently reported medication taken by the cases and both control groups. The odds of caregivers reporting supra-therapeutic paracetamol consumption prior to admission was higher in cases compared to controls (OR 6.6, 95% CI 2.1–21.3). Plasma paracetamol concentration on day of admission was available for 19 cases and exceeded 10 μg/mL in 10/13 samples collected on day one of admission, and 4/9 (44%) collected on day two.
Conclusions-
In a context with limited diagnostic capacity, this study highlights the possibility of supratherapeutic doses of paracetamol as a factor in multi-organ failure in a cohort of children admitted to BJH. In this setting, a careful history of pre-admission paracetamol consumption may alert clinicians to the possibility of overdose, even when confirmatory laboratory analysis is unavailable. Further studies may help define additional toxicological characteristics in such contexts to improve diagnoses.
A cluster of cases of unexplained multi-organ failure was reported in children at Bardnesville Junction Hospital (BJH), Monrovia, Liberia. Prior to admission, children’s caregivers reported antibiotic, antimalarial, paracetamol, and traditional treatment consumption. Since we could not exclude a toxic aetiology, and paracetamol overdose in particular, we implemented prospective syndromic surveillance to better define the clinical characteristics of these children. To investigate risk factors, we performed a case–control study.
Methods-
The investigation was conducted in BJH between July 2015 and January 2016. In-hospital syndromic surveillance identified children with at least two of the following symptoms: respiratory distress with normal pulse oximetry while breathing ambient air; altered consciousness; hypoglycaemia; jaundice; and hepatomegaly. After refining the case definition to better reflect potential risk factors for hepatic dysfunction, we selected cases identified from syndromic surveillance for a matched case–control study. Cases were matched with in-hospital and community-based controls by age, sex, month of illness/admission, severity (in-hospital), and proximity of residence (community).
Results-
Between July and December 2015, 77 case-patients were captured by syndromic surveillance; 68 (88%) were under three years old and 35 (46%) died during hospitalisation. Of these 77, 30 children met our case definition and were matched with 53 hospital and 48 community controls. Paracetamol was the most frequently reported medication taken by the cases and both control groups. The odds of caregivers reporting supra-therapeutic paracetamol consumption prior to admission was higher in cases compared to controls (OR 6.6, 95% CI 2.1–21.3). Plasma paracetamol concentration on day of admission was available for 19 cases and exceeded 10 μg/mL in 10/13 samples collected on day one of admission, and 4/9 (44%) collected on day two.
Conclusions-
In a context with limited diagnostic capacity, this study highlights the possibility of supratherapeutic doses of paracetamol as a factor in multi-organ failure in a cohort of children admitted to BJH. In this setting, a careful history of pre-admission paracetamol consumption may alert clinicians to the possibility of overdose, even when confirmatory laboratory analysis is unavailable. Further studies may help define additional toxicological characteristics in such contexts to improve diagnoses.