Emergency care interventions for pediatric severe acute respiratory infections in low- and middle-income countries: a systematic review and narrative synthesis

Abstract

ABSTRACTBackgroundSevere acute respiratory infections (SARIs) are the leading cause of pediatric death globally, particularly in low- and middle-income countries (LMICs). Given the potential rapid clinical decompensation and high mortality rate from SARIs, interventions that facilitate the early care of patients are critical to improving patient outcomes. The aim of this systematic review was to evaluate the impact of emergency care interventions on improving clinical outcomes of pediatric patients with SARIs in LMICs.MethodsPubMed, Global Health, and Global Index Medicus electronic databases were searched to identify peer-reviewed clinical trials or studies with comparator groups published before November 2020. All studies which evaluated acute and emergency care interventions on clinical outcomes for children (29 days to 19 years) with SARIs conducted in LMICs were included. Given the heterogeneity of interventions and outcomes, a narrative synthesis was performed. Bias was assessed using the Risk of Bias 2 and Risk of Bias in Non-Randomized Studies of Interventions.Results20,583 studies were screened, with 99 meeting criteria for final inclusion. The most common conditions studied were pneumonia or acute lower respiratory infection (61.6%) and bronchiolitis (29.3%). The majority of studies evaluated medications (80.8%), followed by respiratory support (14.1%) and supportive care (5%). The strongest evidence of benefit was found for respiratory support interventions such as improved medical oxygen systems to decrease risk of death. Results were notably inconclusive on the utility of continuus positive airway pressure (CPAP). Mixed results were found for interventions for bronchiolitis, although possible benefit was found for hypertonic nebulized saline to decrease hospital length of stay. Early use of adjuvant treatments such as Vitamin A, D, and zinc for pneumonia and bronchiolitis did not appear to have convincing evidence of benefit on clinical outcomes.ConclusionsWhile the burden of SARI in pediatric populations is high, few emergency care (EC) interventions have high quality evidence for benefit on clinical outcomes in LMICs. Respiratory support interventions have the strongest evidence for decreasing hospital length of stay and mortality and improvement of clinical status. Further research on the use of CPAP in diverse settings and populations is needed. A stronger evidence base for EC interventions for children with SARI, including metrics on the timing of interventions, is greatly needed.