Books & Electronic Media

International child health care: a practical manual for hospitals worldwide

Edited by David Southall, Brian Coulter, Christiane Ronald, Sue Nicholson, & Simon Parke Published by BMJ Books, London, England, 2002. ISBN 0-7279-1476-6, price £55

This large book (626 big pages) takes on an ambitious, arguably impossible, task. It aims to be a comprehensive text for paediatricians in hospitals worldwide: to be a resource (according to the forward) for 'big teaching hospitals', rural hospitals, and village clinics, in emergency and 'chronic' situations, in 'peace and war'. The way in which the authors succeed in some areas and fail in others highlights the difficulty of providing guidelines for paediatric care that are applicable to all situations.

There are many very good chapters. Those on meningitis, orthopaedic conditions and acute diarrhoea provide concise guidelines and appropriate treatment options for settings with varying resources. The chapter on epilepsy outlines an overall approach that could be applied in developing countries, despite gaps in the section on febrile seizures. The chapters on palliative care and grief and loss in war-affected societies are truly needed sensitive approaches to these common and difficult problems for children in the world today.

Failures in other areas highlight the need for a balance between interventions that are affordable and effective in wealthy countries, and the realities and priorities for poor countries. The notion of 'resource steal' is crucial for putting the book into perspective. For example, building up a centre for specialized cardiac or intensive care services (both proposed as theoretical 'minimal standards') might steal essential human and financial resources from primary rural or basic referral level hospital care. Neonatal incubators are recommended but there is no balancing argument outlining their disadvantages in developing countries; "kangaroo" care is only briefly mentioned ('where incubators are not available') and other low-cost alternatives such as "warm-room" care are largely ignored.

The book could be seen as having two main themes: one a philosophy of care, and the other the technical aspects of paediatric medicine and nursing. The thesis is that much of the technical requirement for care should somehow be based on 12 philosophical standards of care, as defined by the Child Friendly Hospital Initiative of Child Advocacy International. These 12 standards are in turn based on the UN Convention of the Rights of the Child. The principle is that sick children everywhere deserve a certain standard of care. The editors are staff from Child Advocacy International, a UK nongovernmental organization that aims to assist health workers in poor countries to improve hospital care for children.

This combination of moral and technical concerns does not always work very well. Some of the recommendations lack sufficient scientific evidence or do not take account of the extreme resource limitations of many developing countries. The book states, for example, that 'ultrasound equipment should be available in every institution that merits the title of Hospital', and that non-invasive respiratory support constitutes a minimal standard of care for acute respiratory infections. In reality, though, a hospital is better judged by patient outcomes than by its equipment.

Negative pressure ventilation is recommended for acute lower respiratory infection, but even in resource-rich neonatal intensive care units this procedure has proved difficult, expensive and potentially hazardous. In a serious approach to evidence-based paediatric care, negative pressure ventilation might be suggested as an option for post-operative respiratory support for children with a Fontan circulation and for home ventilation of children with chronic neuromuscular disease, not for pneumonia in developing countries. Instead, it would have been better to describe the least expensive ways to deliver oxygen. Once oxygen supplies are guaranteed, clearer detail could be given on a practical method to make and use a simple CPAP circuit in level 2 or 3 hospitals.

Although the book advocates appropriate technology, there are many messages about the superiority of high technology equipment and drugs. It needs to be emphasized that in many cases appropriate technology is not inferior; it is simpler, makes more efficient use of resources, and is more robust. There is too little recognition that complex technology is harmful if staff are not able to use it properly.

It is not always clear when the authors believe that the "Minimum Standard Requirements" highlighted in the shaded boxes at the start of each chapter represent what should be available in every hospital, in secondary hospitals, or in one tertiary referral hospital within the country. Also the implied link between these and human rights is tenuous.

As is common in multi-authored books, some of the recommendations are contradictory. For example, age-appropriate respiratory rates and those that indicate respiratory distress, and dosing intervals for gentamicin differ in different chapters. Recommendations on the use of intracardiac drugs for neonatal resuscitation conflict with those of the Neonatal Resuscitation Program of the American Academy of Pediatrics, whose programme is promoted in a separate chapter on self-instructional courses in neonatal resuscitation. Some statements show an incomplete grasp of the existing evidence, others are wrong, poorly worded or inappropriate (examples can be given on request; I do not have room to cite them here). The diagnostic algorithms are difficult to follow with floating boxes and missing arrows, and some lack perspective: a health worker following the difficult breathing algorithm would need to consider volatile substance inhalation, and organophosporous poisoning, before considering pneumonia.

Having said all that, much can be learnt from this book. Many of the chapters are well written and contain excellent condensed technical information that has not been presented before. Perhaps the most important thing this book makes clear is that reliable up-to-date, low-cost, evidence-based guidelines for paediatric care in hospitals in developing countries are urgently needed, but they have to reflect an appropriately balanced use of resources. They also need to target specific settings of care, to emphasize low-cost simple technology options and drugs, and to be sensitive to the efforts of health workers. Furthermore, they need to consist of the strongest evidence available, and either to be peer-reviewed internationally or endorsed by the consensus of experts consisting predominantly of doctors and nurses from resource-poor settings. Other recently published manuals and some older texts come closer to meeting these requirements.

Trevor Duke¹

¹ Centre for International Child Health, Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Flemington Road, Parkville 3052, Victoria Australia (email: duket@cryptic.rch.unimelb.edu.au).