Review

Global paediatric advanced life support: improving child

survival in limited-resource settings
Mark E Ralston, Louise T Day, Tina M Slusher, Ndidiamaka L Musa, Helen S Doss

Lancet 2013; 381: 25665 Nearly all global mortality in children younger than 5 years (99%) occurs in developing countries. The leading causes
Department of Pediatrics, of mortality in children younger than 5 years worldwide, pneumonia and diarrhoeal illness, account for 1396 and
Naval Hospital, Oak Harbor, 0801 million annual deaths, respectively. Although important advances in prevention are being made, advanced life
WA, USA (M E Ralston MD);
support management in children in developing countries is often incomplete because of limited resources. Existing
Department of Pediatrics,
Uniformed Services University advanced life support management guidelines for children in limited-resource settings are mainly empirical, rather
of the Health Sciences, than evidence-based, written for the hospital setting, not standardised with a systematic approach to patient
Bethesda, MD, assessment and categorisation of illness, and taught in current paediatric advanced life support training courses from
USA (M E Ralston); Department
the perspective of full-resource settings. In this Review, we focus on extension of higher quality emergency and
of Pediatrics, LAMB Hospital,
Parbatipur, Dinajpur 5250, critical care services to children in developing countries. When integrated into existing primary care programmes,
Bangladesh (L T Day MRCPCH); simple inexpensive advanced life support management can improve child survival worldwide.
Center for Global Pediatrics,
University of Minnesota,
Pediatric Intensive Care Unit,
Introduction countries has been identied as crucial to substantially
Hennepin County Medical In developing countries, important progress has been reduce global mortality in children younger than 5 years.8
Center, Minneapolis, MN, USA made over the past few decades in the treatment of Toward this end, paediatric advanced life support, broadly
(T M Slusher MD); Division of critically ill children. In these countries, the burdens of dened as emergency management beyond cardio-
Critical Care, Department of
Pediatrics, Medical College of
global paediatric population, life-threatening disease, pulmonary resuscitation or automated external debril-
Wisconsin, Milwaukee, WI, USA and mortality are the greatest; low living standards and lator in children outside the neonatal period, can be
(N L Musa MD); and SIL Clinic, poor hygiene, combined with widespread malnutrition improved in limited-resource settings. In this Review, we
Ukarumpa, Papua New and multiple concurrent illnesses, further increase the provide an overview of paediatric advanced life support
Guinea (H S Doss MD)
complexity of disease.13 Advancements in the manage- management in limited-resource settings, with a focus
Correspondence to:
Dr Mark E Ralston, Department
ment of severe infection and shock have been achieved on recent developments and proposed solutions.
of Pediatrics, Naval Hospital, Oak with the introduction of paediatric critical care medicine
Harbor, WA 98278, USA and recommendations endorsed by WHO.4 Despite Improvement of paediatric advanced life support
mark.ralston@med.navy.mil much eort to guide health-care practitioners in the care management with increased access to resources
of children with serious conditions, progress towards a Paediatric advanced life support management in
substantial reduction in global mortality in children developing countries, if practised, is often incomplete
younger than 5 years has been disappointing.57 Limit- because of low availability of resources, including
ations in resources and poor health-care systems in limitations in disease surveillance and reporting systems,
developing countries jeopardise critically ill children referral services from primary health centres, structural
whose survival depends on timely attention to life models for emergency medical services, transport
support. Development of more eective paediatric services, emergency care centres, triage systems, trained
emergency and critical care services in developing health-care professionals in paediatric emergency and
critical care medicine, hospital infrastructure for critically
ill patients, intensive care units, pharmacies, laboratories,
Search strategy and selection criteria radiology departments, blood banks, equipment (eg,
We searched the Cochrane Library, PubMed (Medline), and Embase databases from 1945 monitors, infusion pumps, and ventilators), and
to December, 2011. We used the Medical Subject Headings (MeSH) terms respiration disposable materials.3,4,823 In low-income countries,
disorders, arrhythmias, cardiac , heart arrest, shock, pneumonia, or diarrhea, and critically ill children often do not have access to oxygen
the keywords respirat*, heart, cardiac, shock, pneumonia, diarrhea, or their caregivers have no equipment to detect
gastroenteritis, emergenc*, triage, or resuscitat*. These results were limited to hypoxaemia.15,2224 Panel 1 shows examples of other
include children younger than 12 years of age and focused on developing countries with deciencies reported by specic regions.
the following lter: developing countries[MeSH] OR refugees[MeSH] OR poverty Advanced life support management and outcomes in
areas[MeSH] OR poverty[MeSH] OR vulnerable populations[MeSH] OR vulnerable critically ill children in developing countries can be
populations[MeSH] OR Africa[MeSH] OR (Asia[MeSH] NOT Japan[MeSH]) OR improved with increased access to resources,8,23,3032
South America[MeSH] OR Pacic Islands[MeSH] OR Indian Ocean Islands[MeSH] OR which can be achieved with improved use of existing
Indian Ocean Islands[MeSH] OR Europe, Eastern[MeSH] OR Transcaucasia[MeSH] resources and increased expenditure to obtain needed
OR South America[MeSH] OR Mexico[MeSH] OR Latin America[MeSH] OR Central resources and develop a more eective continuum of
America[MeSH] OR Caribbean Region[MeSH]. We identied additional citations from care.4,8,10,33,34
the reference lists of articles that we retrieved in the search strategy. We used a web search A rough breakdown of paediatric advanced life support
to identify several websites and online handbooks. resources into three levels of capability is proposed in
table 1. Higher-level capability does exist but is rare.16

256 www.thelancet.com Vol 381 January 19, 2013


Modication of international advanced life
support guidelines to represent a dierent
disease range
The disease range in children in limited-resource settings
diers from that of developing countries. Many existing
advanced life support guidelines are applicable to
developed countries, but eorts are underway to create
separate guidelines for children with unique presen-
tations common to low-income countries.16,36,37 Examples
of these unique presentations that potentially require
dierent advanced life support management compared
with traditional recommendations originating in
developed countries include sepsis, malnutrition, micro-
nutrient deciencies, measles, and HIV.
In sepsis, bolus uid resuscitation with saline or
albumin in children with severe infection and shock (ie,
in settings with a high prevalence of malaria) increases
48 h mortality in Africa.38 In children with dengue shock
syndrome, early aggressive uid resuscitation combined
with careful uid removal and early use of colloid may be
the preferred treatment option.3942
Severely malnourished children with infection (eg,
pneumonia) have a dierent and typically more critical
presentation, a dierent range and frequency of causative
organisms, and a higher mortality risk than children who
are not severely malnourished.2,4348 Aggressive uid
resuscitation in children with severe acute malnutrition
and shock could have adverse eects.16,49
In children with vitamin A deciency, the mortality
risk resulting from diarrhoea, measles, and malaria is
increased by 2024%.50 In children with zinc deciency,
the mortality risk attributable to diarrhoea, pneumonia,
and malaria is increased by 1321%.51
Critically ill children with measles often have con-
comitant pneumonia and diarrhoea52 and have a higher
mortality risk than children without measles.2
Children with HIV infection have a dierent range of
causative organisms with higher rates of antibiotic
resistance, greater incidence of polymicrobial disease,
more severe morbidity (including treatment failure), and
a higher mortality risk than children without HIV.2,5355
Reduction of global paediatric mortality with
simple, inexpensive treatment
Nearly all global mortality in children younger than
5 years (99%) occurs in developing countries: 49% in
sub-Saharan Africa, 33% in south Asia, and 17% in
other regions.6 The leading causes worldwide are
pneumonia and diarrhoeal illness, accounting for about
1396 million and 0801 million deaths every year,
respectively.56 The global burden of these diseases
occurs disproportionately in settings where limitations
in health-care resources are greatest.1,5
To achieve United Nations Millennium Development
Goal (MDG) 4, which is a two-thirds reduction of
mortality in children younger than 5 years from 1990
rates by 2015, substantial improvements in the delivery
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Review
Panel 1: Deciencies in care of critically ill children reported by region
Africa
In urban Guinea-Bissau, 16% of acutely ill children die either on the way to the hospital or
while waiting at an outpatient clinic.25 In Kenya, many items that are necessary for care of
seriously ill children are not available at district hospitals.19 In Uganda, a third of deaths
attributable to pneumonia in children younger than 5 years occur at home, nearly a third
of severely ill children receive a completed referral for hospital care after 2 weeks, and
most anaesthetists do not have the facilities to give anaesthesia safely to children.2628 In
Tanzania, almost half of children referred for hospital care take 2 days or longer to arrive
at a hospital, and only one specialist in anaesthesia and intensive care exists for every
3 million people.8,29 In Zambia, only 7% of hospitals where doctors undertake surgery and
anaesthesia have an intensive care unit.21 In Zimbabwe, emergency medical services are of
a highly variable standard, with long response times and transport distances, and
underdeveloped and poorly resourced rural services and urban emergency departments.14
Southeast Asia
In India, there is essentially no eectively run or supported transport system.11
Western Pacic
In Mongolia, the implementation of sepsis guidelines has been hindered because of
shortages of required facilities, equipment, drugs, and disposable materials.3
Americas
In Brazil, many children with shock never receive health-care services, and almost all of those
admitted to public hospitals do not receive basic care because of insucient resources.30
of health care in low-income countries are needed.5,8
Although important advancements towards MDG 4 have
been made with regard to prevention of mortality, one of
the weakest links in the health-care systems of these
countries has been identied as the delivery of paediatric
emergency and critical care services.8,10,15
Paediatric mortality resulting from pneumonia and
diarrhoeal illness in limited-resource settings is mostly
avoidable by simple, inexpensive advanced life support
interventions.4,8,22 A system of emergency triage and
treatment has been implemented in Malawi at a cost of
US$175 per child.13
Several cost considerations pertain to pneumonia and
diarrhoea. In Papua New Guinea, mortality in children
with pneumonia was reduced by up to 35% with an
oxygen systems strategy (ie, improved access to oxygen
through oxygen concentrators and pulse oximetry),
which costs $51 per child treated and $50 per disability-
adjusted life-year averted.22,57 This strategy has been
compared with vaccine development and delivery as a
cost-eective means to improve the quality of child
health care.22,57 The average minimum costs to treat a
child with pneumonia in Pakistan are $1344 for
outpatient therapy and $71 for inpatient therapy.58
Oral rehydration solution has reduced mortality in
children with acute diarrhoeal illness by saving about
50 million lives since the 1970s. At a cost of $030 per
treatment, the combination of oral rehydration solution
and zinc reduces the risk of death in a child with acute
diarrhoea to close to zero.5962 Although oral rehydration
solution is widely available in the community setting, the
257
 Review
Level 1
Continuum of Pre-hospital emergency care
care
Facility Home, community health oce, or clinic
System Referral, transport (simplied BLS)
Personnel Family caregiver and community health
worker, paramedic or medical assistant,
nurse
Laboratory None
Radiology None
Equipment Stethoscope , MDI and spacer,
disposables intravenous catheter, intravenous uid nasopharyngeal catheter, nebuliser*, bag
infusion set, nasogastric tube, nebuliser mask device, intravenous catheter,
Monitoring Respiratory rate, heart rate, temperature,
capillary rell time
Medication Antibiotics, oral rehydration solution,
uids ReSoMal, zinc, albuterol/salbutamol/
ipratropium (nebulisation solution or MDI),
isotonic crystalloid
Management Oral or intramuscular medication, oral
rehydration, warming techniques, overnight
monitoring, vagal manoeuvres,
bronchodilator therapy (nebuliser* or MDI
and spacer), intravenous medication,
nasogastric or intravenous or intraosseous
uid resuscitation
Resources at successive levels are cumulative; =presence or absence of resource depending on locality. ICU=intensive care unit. BLS=basic life support. CBC=complete blood
count. MDI=metered-dose inhaler. CPAP=continuous positive airway pressure. NIPPV=non-invasive positive pressure ventilation. ReSoMal=rehydration solution for
malnourished children. *Indicates resources requested for level 1.35
Table 1: Levels of paediatric advanced life support resources in limited-resource settings
cost of inpatient oral rehydration solution treatment is
estimated to be $75.63 Introduced in 2001, low-osmolarity
oral rehydration solution reduces the need for intra-
venous hydration by about 40% compared with WHO
standard oral rehydration solution (MantelHaenszel
odds ratio 059, 95% CI 045079).64
Inclusion of entire continuum of care in
advanced life support guidelines
Universally, poor-quality care has the most severe
consequences for children with time-sensitive critical
conditionseg, severe infection, hypoxia due to respira-
tory illness, hypovolaemia due to diarrhoea, and injury
(both accidental and non-accidental).8,10,26 Ideally, paed-
iatric advanced life support training and management
guidelines in limited-resource settings should be
expanded to the entire continuum of care of critically ill
children. The model continuum of care, from pre-hospital
care to post-critical care, has been described for developing
countries, although in reality it is rarely available.4,8,10,14,34
258
Level 2 Level 3
Pre-hospital emergency care, hospital Hospital emergency and critical care
emergency and critical care
Primary health centre, rural hospital District hospital, emergency treatment centre,
hospital ward, ICU
Referral, transport (simplied BLS), hospital Triage, hospital management
management
Nurse, paramedic or medical assistant, health Paediatrician, physician (internal medicine),
extension ocer, nurse practitioner, doctor surgeon, obstetrician and gynaecologist
Blood glucose (rapid), haemoglobin/ CBC, basic chemistries, body uid culture,
haematocrit, urinalysis, malaria smear, type blood bank
and crossmatch, CBC
Plain radiography, ultrasound Plain radiography and ultrasound
Oxygen concentrator*, nasal prongs, Oxygen cylinder, oxygen mask, oxygen mask
with reservoir bag, CPAP device, urinary
catheter, 12-lead electrocardiogram, NIPPV
intravenous uid infusion set, nasogastric device, endotracheal tube, end-tidal
tube*, suction device*, CPAP device carbon dioxide device, monitor/debrillator,
external automated debrillator, chest
tube, tracheostomy tube
Urine output, blood pressure (with Blood pressure (with appropriate cu ), pulse
appropriate cu), pulse oximetry* oximetry, continuous electrocardiogram
Oxygen*, dextrose*, albuterol/salbutamol/ Diphenhydramine, epinephrine 01 mg/mL,
ipratropium (nebulisation solution or MDI), dopamine, aminophylline, furosemide
epinephrine 1 mg/mL, isotonic crystalloid,
corticosteroids, whole blood,
diphenhydramine
Free-ow oxygen delivery*, suctioning*, CPAP ventilation, NIPPV,
bronchodilator therapy (nebuliser* or MDI debrillation, synchronised cardioversion,
and spacer), manual ventilation (bag mask), vasoactive therapy, antiarrhythmic
intravenous medication, nasogastric or therapy, bronchoscopy, tracheostomy,
intravenous or intraosseous uid needle decompression or tube
resuscitation, hypoglycaemia treatment*, thoracostomy
blood transfusion, CPAP ventilation
Throughout low-income countries, deciencies in the
continuum of care for children with critical illness or
injury have been identied. For lay caregivers, know-
ledge gaps exist regarding the recognition and
treatment of serious conditions.65 Children in need of
emergency care often do not reach even the simplest
health-care facilities.26,30 For health-care providers,
paediatric advanced life support guidelines are largely
absent for the pre-hospital setting; within the present
primary health-care programme, Integrated Manage-
ment of Childhood Illness (IMCI), emergency con-
ditions in children, which account for roughly 1020%
of visits, are handled with urgent referral to hos-
pital.35,6668 However, referral processes are decient
because of cost and other resource limitations, and
transport services are often inadequate.912,25,27,29,33 Poor-
quality hospital care remains widespread in low-income
countries.10,15,17,19,30,31,69,70 About 50% deaths of children
admitted to hospital in developing countries occur
within 24 h of admission.71
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A logical next step to improve the continuum of care of
critically ill children in limited-resource settings is to
integrate advanced life support guidelines within the
framework of IMCI. In these settings where most of the
worlds population resides, the local community expects
universal access to emergency care provided by the
primary care system.10,34 Furthermore, pre-hospital emer-
gency care in developing countries is cost eective.13,34 It
can be provided by medical personnel (eg, paramedics)
and non-medical personnel (eg, lay responders and
commercial vehicle drivers).34 In Mexico, training of
caregivers and rst-level health-care providers resulted in
substantial reductions in paediatric mortality due to acute
respiratory illness and diarrhoeal illness (ie, by 43% and
36%, respectively, in children younger than 1 year, and by
39% and 34%, respectively, in children younger than
5 years).72 In nine communities across southeast Asia and
Africa, pneumonia case management intervention was
associated with a reduction in pneumonia mortality of
36% (95% CI 2048%) and 36% (2049%) among infants
(<1 year) and children (04 years), respectively.73
Although minimum standards for emergency care in
limited-resource settings are not well dened, rst-level
responders should be empowered and equipped to start
appropriate, time-sensitive, and potentially life-saving
management, especially for infants and children with
reversible disorders in settings with substantial barriers
to referral and transport.10,27,29,35 Simple equipment and
supplies have been requested for level 1 care to stabilise
severely ill children in sub-Saharan Africa.35 Additionally,
more specic IMCI referral criteria for serious conditions
are needed, thereby reducing unnecessary expenditure of
resources at referral destinations;27,68 In 2012, WHO
modied their referral guidelines for pneumonia.74 In
some limited-resource settings, simpler modes of
emergency transport have been used because of resource
constraints (eg, if there are no motorised vehicles or
scarce fuel supplies) and poor or non-existent roads.10
At the hospital level, strategies to improve the overall
quality of care for children in low-income countries are
in progress.69 Emergency Triage Assessment and
Treatment (ETAT) guidelines have been incorporated
within the WHO Pocket Book of Hospital Care for Children
to improve paediatric advanced life support manage-
ment.18,7577 The use of ETAT guidelines in Malawi resulted
in a roughly 50% reduction in inpatient mortality.13
Furthermore, expansion of the realistic notion of the
limited-resource intensive care unit, oering continued,
time-sensitive treatment that is practical to local needs
and limitations, has been proposed.4,78
Standardisation of advanced life support
management
Existing advanced life support management in children in
limited-resource settings is not standardised with a
systematic approach to patient assessment and categor-
isation of illness.8,15,18,30 No standardisation could result in
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Review
under-recognition of severe clinical illness (eg, hypoxaemia,
pneumonia, and shock).26,79,80 A systematic approach to
patient assessment and accurate categorisation of illness
could result in early recognition of critical disorders,
appropriate treatment, and improved outcomes in specic
conditions, including pneumonia and shock.4,22,30,33,43,70,72,81
ETAT plus Admission Care (ETAT+), a paediatric
advanced life support course that builds on the original
WHO ETAT course and ETAT guidelines, is available to
assist health-care providers dealing with paediatric
emergencies at the hospital level in developing
countries.16,18,37,7577,82 Several other paediatric advanced life
support courses, mostly originating in full-resource
settings, oer a range of curricula, including an ABCDE
approach to patient assessment, a standardised system
to categorise critical illness in children, and recognition
and treatment of specic emergency medical and
trauma conditions.
Substitute resource
Respiratory distress and failure
Oxygen cylinder Oxygen concentrator (with power supply)22
Pulse oximetry Clinical indicators of hypoxaemia85
Chest radiography Clinical indicators of pneumonia;86,87 clinical tool predicting treatment
failure of severe pneumonia88
Oxygen mask Nasal prongs or nasopharyngeal catheter85
Oxygen mask with reservoir bag CPAP (nasal)89
Nebuliser MDI and spacer (sealed bottle)90
Mechanical ventilation CPAP (bubble),9193 NIPPV (with power supply)9496
CPAP (bubble) Pressurised room air technology (with power supply)97
Racemic epinephrine Epinephrine 1 mg/mL98
Shock
BP cu (use appropriate size for age) Clinical indicator of hypotension is non-palpable peripheral pulses99
ScVO2 70% CRT 2 s100
Intraosseous needle Bone marrow needle;101 large-bore standard hypodermic needle;101
short, wide-gauge spinal needle with internal stylet101
Dopamine (by central line) Dopamine (by peripheral line)16
Bradycardia with pulse and poor perfusion
Epinephrine 0.1 mg/mL Dilute 1 mL of epinephrine 1 mg/mL by adding 9 mL normal saline102
Supraventricular tachycardia
Ice (for vagal manoeuvres) or Digoxin (for termination and maintenance*);103,104 propanolol (for
synchronised cardioversion or maintenance*)103,104
adenosine or amiodarone or
procainamide
Ventricular tachycardia with pulse
Synchronised cardioversion or Quinidine;105,106 propranolol105,106
amiodarone or procainamide
Cardiac arrest
Manual debrillation Automated external debrillator101
Epinephrine 0.1 mg/mL Dilute 1 mL of epinephrine 1 mg/mL by adding 9 mL normal saline102
Consider the external jugular vein as a viable site with a low complication rate for central venous access.107
CPAP=continuous positive airway pressure. MDI=metered-dose inhaler. NIPPV=non-invasive positive pressure
ventilation. BP=blood pressure. ScVO2=central venous oxygen saturation. CRT=capillary rell time. *Consider propranolol
as rst-line treatment (ie, preferable to digoxin) for maintenance in most cases of supraventricular tachycardia because
of the concern about Wol-Parkinson-White syndrome and possible atrial brillation with antegrade conduction over the
bypass tract (Atkins D, University of Iowa Hospital and Clinics, Iowa City, IA, USA, personal communication).
Table 2: Substitute paediatric advanced life support interventions in limited-resource settings
259
 Review
Panel 2: International, evidence-based paediatric advanced life support guidelines applicable to limited-resource settings
Oxygen
Clinical indicators of hypoxaemia: central cyanosis, nasal
aring, inability to drink or feed, grunting, lethargy;
consider severe chest retractions, respiratory rate
>70 breaths per min, and head nodding74
Pulse oximetry: use to detect hypoxaemia and to guide
oxygen therapy74
Indications for oxygen therapy: SpO2 90% (2500 m above
sea level); SpO2 87% (>2500 m above sea level)74
Oxygen delivery systems: nasal prongs are preferred in
children <5 years of age; use nasal or nasopharyngeal
catheters if nasal prongs are unavailable74
Pneumonia
Antibiotics (in children aged 259 months)74
Very severe pneumonia (cough or dicult breathing,
chest indrawing, and presence of danger signs
[lethargy, unconsciousness, inability to drink or
breastfeed, persistent vomiting, central cyanosis,
severe respiratory distress, or convulsions]): ampicillin
50 mg/kg per dose or benzylpenicillin 50 000 units/kg
per dose intravenously or intramuscularly every 6 h
plus gentamicin 75 mg/kg per dose intravenously or
intramuscularly every 24 h for at least 5 days;
ceftriaxone sodium intravenously or intramuscularly if
treatment failure
Severe pneumonia (cough or dicult breathing, lower
chest indrawing, and no danger signs): amoxicillin
40 mg/kg per dose orally twice daily for 5 days
Non-severe pneumonia (cough or dicult breathing,
fast breathing, and no danger signs) and no wheeze:
amoxicillin 40 mg/kg per dose orally twice daily for
3 days (if low HIV prevalence) or for 5 days (if high HIV
prevalence); referral if treatment failure
Non-severe pneumonia and wheeze: antibiotics are not
recommended as the cause is probably viral
Diarrhoea
Fluid resuscitation (in an infant or child without
malnutrition)113
No signs of dehydration (uid decit <5% bodyweight):
oral rehydration solution for replacement of ongoing
losses (ie, after each loose stool give 50100 mL if
<2 years of age or 100200 mL if 210 years of age)
Some dehydration (uid decit 510% bodyweight): oral
rehydration solution (oral or nasogastric) 75 mL/kg over
4 h in frequent small amounts plus give replacement of
ongoing losses
Severe dehydration (uid decit >10% bodyweight):
isotonic crystalloidRingers lactate or normal saline
(intravenous) 100 mL/kg (30 mL/kg over 1 h then
70 mL/kg over 5 h if <12 months of age; 30 mL/kg over
30 min then 70 mL/kg over 2.5 h if 12 months of age);
can repeat as needed to restore normotension (detectable
radial pulse); if intravenous therapy is unavailable, give
260
oral rehydration solution (nasogastric or oral) 120 mL/kg
over 6 h (20 mL/kg per h); with an improved level of
consciousness give oral rehydration solution (oral or
nasogastric ) 75 mL/kg over 4 h in frequent small
amounts and replacement of ongoing losses
Antibiotics for bloody diarrhoea: ciprooxacin 15 mg/kg per
dose orally twice daily for 3 days; ceftriaxone sodium
5080 mg/kg per dose intravenously or intramuscularly
daily for 3 days if treatment failure; follow guidelines
according to local sensitivities74
Zinc: 10 mg per dose (<6 months of age) or 20 mg
per dose (6 months of age) orally every 24 h for
1014 days102,113,114
Sepsis/septic shock
Pediatric Sepsis Initiative (septic shock)36,115
0 min: recognise decreased mental status and perfusion;
maintain airway and establish vascular access according
to Pediatric Advanced Life Support Guidelines101
5 min: push 20 mL/kg isotonic saline or colloid boluses
up to and over 60 mL/kg; correct hypoglycaemia and
hypocalcaemia
15 min: observe if uid-responsive shock; begin
dopamine therapy if uid-refractory shock (see further
details of Pediatric Sepsis Initiative)
Antibiotics for acute bacterial meningitis74
Empiric treatment: ceftriaxone sodium 50 mg/kg per
dose intravenously every 12 h (can substitute with
100 mg/kg per dose once daily), or cefotaxime sodium
50 mg/kg per dose intravenously every 6 h for
1014 days
No known signicant resistance to chloramphenicol
and -lactam antibiotics: chloramphenicol 25 mg/kg
per dose plus ampicillin 50 mg/kg per dose
intramuscularly or intravenously every 6 h, or
chloramphenicol 25 mg/kg per dose plus
benzylpenicillin 100 000 units/kg per dose
intramuscularly or intravenously every 6 h
Antibiotics for typhoid fever: ciprooxacin 15 mg/kg per
dose orally twice daily for 710 days; ceftriaxone sodium
80 mg/kg per dose intravenously every 24 h for 57 days, or
azithromycin 20 mg/kg per dose orally every 24 h for
57 days, if treatment failure; follow guidelines according to
local sensitivities74
Malnutrition
Antibiotics for severe acute malnutrition (with
complications): benzylpenicillin 50 000 units/kg per dose, or
ampicillin 50 mg/kg per dose, intramuscularly or
intravenously every 6 h for 2 days, then amoxicillin
15 mg/kg per dose orally every 8 h for 5 days plus
gentamicin 75 mg/kg per dose intramuscularly or
intravenously every 24 h for 7 days74
SpO2=oxygen saturation measured by pulse oximetry.
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 Review

Expansion of the usefulness of existing Establishment of international, evidence-based

paediatric advanced life support courses
Existing advanced life support guidelines for children
as taught in present paediatric advanced life support
courses are mostly applicable to settings that have full
resources. For this reason, these advanced life support
courses do not have universal applicability, despite
their international acceptance.18,32,70,75,76,83 Furthermore,
the eectiveness of these courses in improving out-
comes in developing countries has not been shown.84 A
revised curriculum with evidence-based application in
limited-resource settings would expand their usefulness
worldwide. There is also a need for trials assessing the
eectiveness of refresher advanced life support courses
in improving long-term practice by health-care pro-
fessionals in developing countries.84 Advanced life
support training, appropriately adapted for use in
limited-resource settings, needs wider dissemination
from the community health level to larger hospital
settings.
Alternative approaches to assessment and management
are available to help practitioners who care for severely ill
children without having the full complement of resources
available to them. Table 2 lists examples of these
alternative approaches that can be considered in limited-
resource settings.
advanced life support guidelines
Many existing advanced life support guidelines for
children in limited-resource settings are empirical, rather
than evidence-based.24,102 Examples include: avoidance of
oxygen masks for free-ow oxygen delivery; use of small
intravenous uid boluses and thereafter blood transfusion
in severe acute malnutrition and shock; and widespread
use of broad-spectrum antibiotics in sepsis.16,102,108
Justication for empirical guidelines includes both
pragmatism in limited-resource settings (eg, an oxygen
mask consumes more oxygen compared with nasal
prongs or a nasopharyngeal catheter) and insucient
evidence.109 There is an identied need for international,
evidence-based, paediatric advanced life support manage-
ment guidelines for diseases common to limited-resource
settings. Examples include uid resuscitation in severe
infection and shock, antibiotic management in sepsis, and
management of severe acute malnutrition (eg, sepsis,
uid resuscitation, and nutritional support).16,32,43,46,49,54,66,95,110,111
In addition to management guidelines, training guidelines
are needed, including instruction in airway skills and
implementation and maintenance of an oxygen system
using pulse oximetry and oxygen concentrators.12,33,112
International advanced life support guidelines for chil-
dren in limited-resource settings should be established

Upper airway Lower airway Lung tissue disease Disordered control

obstruction obstruction of breathing
Levels 1, 2, and 3
Open airwaysuctioning, positioning, manoeuvres Maintainable airway Maintainable airway Maintainable airway Maintainable airway
(head-tilt chin lift/jaw thrust), adjuncts (NPA/
OPA)102
Antibiotics (oral, intramuscular or intravenous)74,102 Diphtheria, epiglottitis, Pneumonia (suspected
bacterial tracheitis bacterial)
Bronchodilatoralbuterol/salbutamol, ipratropium Asthma, bronchospasm
(MDI or nebuliser)102
Levels 2 and 3
Corticosteroid (oral or intramuscular)102 Croup, airway oedema Asthma, bronchospasm
Epinephrine 1 mg/mL (nebuliser)102 Croup, airway oedema
Pulse oximetry74,102 Clinical signs of Clinical signs of Clinical signs of Clinical signs of
hypoxaemia hypoxaemia hypoxaemia hypoxaemia
Free-ow oxygen (nasal prongs, nasopharyngeal Hypoxaemia Hypoxaemia Hypoxaemia Hypoxaemia
catheter, oxygen mask with or without reservoir)74,102
Bag mask ventilation101 Respiratory failure Respiratory failure Respiratory failure Respiratory failure
CPAP ventilation89,9193 Respiratory failure Respiratory failure Respiratory failure Respiratory failure
Level 3
NIPPV94,96 Respiratory failure Respiratory failure Respiratory failure Respiratory failure
Furosemide (intravenous or intraosseous)101 Pulmonary oedema
Aminophylline (oral or intravenous)102 Apnoea
Bronchoscopy102,116 Foreign body
Tracheostomy102,116,117 Severe UAO

NPA=nasopharyngeal airway. OPA= oropharyngeal airway. MDI=metered-dose inhaler. CPAP=continuous positive airway pressure. NIPPV-non-invasive positive pressure
ventilation. UAO=upper airway obstruction.

Table 3: Paediatric advanced life support interventions adapted for use in limited-resource settings for respiratory distress and failure

www.thelancet.com Vol 381 January 19, 2013 261

 Review

Hypovolaemic Distributive Cardiogenic Obstructive

Levels 1, 2, and 3
Low-osmolarity ORS (oral or nasogastric)102,113 Compensated shock Compensated shock Compensated shock Compensated shock
ReSoMal* (oral or nasogastric)102,108 Compensated shock with Compensated shock Compensated shock with Compensated shock with
malnutrition with malnutrition malnutrition malnutrition
Zinc (oral)102,113,114 Diarrhoea
Antibiotics (oral, intramuscular, or Bloody diarrhoea, Sepsis
intravenous)74,102,118 cholera
Vagal maneouvresice or other101 SVT
Isotonic crystalloidnormal saline, Ringers Hypotension (with or Hypotension (with or Hypotension (with or Hypotension (with or
lactate (intravenous or intraosseous)36,102,113,115 without malnutrition) without malnutrition) without malnutrition) without malnutrition)
Warming techniquesskin-to-skin, clothing, Hypothermia Hypothermia Hypothermia Hypothermia
hats, blankets, heat, or other102
Levels 1 and 2
Dextrose (oral, intravenous or intraosseous)36,102,115 Hypoglycaemia Hypoglycaemia Hypoglycaemia Hypoglycaemia
Whole blood (intravenous or intraosseous)102 Severe anaemia
Epinephrine 1 mg/mL (intramuscular)102 Anaphylaxis
Corticosteroid (oral or intramuscular)102 Anaphylaxis
Diphenhydramine (intramuscular, intravenous Anaphylaxis
or intraosseous)101
Level 3
Vasoactive therapy (intravenous or Hypotension, myocardial Hypotension, myocardial Hypotension, myocardial Hypotension, myocardial
intraosseous)36,102,115 dysfunction, CHF dysfunction, CHF dysfunction, CHF dysfunction, CHF
Furosemide (intravenous or intraosseous)102 CHF
Epinephrine 0.1 mg/mL (intravenous or Bradycardia with pulse
intraosseous)101 and poor perfusion
Antiarrhythmic therapy (intravenous or SVT, VT with pulse
intraosseous)101,103,104
Synchronised cardioversion101 SVT, VT with pulse
Needle decompression or Tension pneumothorax
tube thoracostomy101

ORS=oral rehydration solution. ReSoMal=rehydration solution for malnourished children. SVT=supraventricular tachycardia. CHF=congestive heart failure. VT=ventricular
tachycardia. *Recommendations for treatment of dehydration in the infant or child with severe acute malnutrition specify ReSoMal instead of standard ORS.102,108

Table 4: Paediatric advanced life support interventions adapted for use in limited-resource settings for shock

and regularly updated on the basis of a review of present
evidence. Panel 2 shows existing examples of international,
evidence-based paediatric advanced life support guidelines
applicable to limited-resource settings.
Tables 3 and 4 provide a summary of paediatric
advanced life support interventions that might be useful
to manage children with respiratory distress or failure
and shock in limited-resource settings.
Conclusions
Over the past decades, advanced life support management
has contributed to a substantial reduction in child
mortality in developed countries. Securing of real
progress toward a global reduction in mortality in
children younger than 5 years will need continued and
improved eorts at both the prevention and treatment of
life-threatening disorders. Paediatric emergency and
critical care is limited in the regions of the world where
nearly all global childhood deaths occur. Improvement in
paediatric advanced life support management, particu-
larly in the pre-hospital setting where it is almost
non-existent, is crucial. First, a review of present evidence
leading to comprehensive international paediatric
advanced life support guidelines considering the low
resources and dierent disease range of low-income
countries is needed. This review will drive improved
training programmes, research, and clinical outcomes.
Although improvements in health-care systems in
limited-resource settings can seem to happen slowly,
simple and inexpensive advanced life support manage-
ment, when integrated into existing programmes of
primary care, can go a long way towards improving child
survival worldwide.
Contributors
MER, LTD, and HSD made a signicant contribution to the writing of the
manuscript. TMS made a signicant contribution to the writing of tables 1
and 2. NLM made a signicant contribution to the writing of table 2.
Conicts of interest
We declare that we have no conicts of interest.
Acknowledgments
We thank Dianne Atkins, Trevor Duke, Mike English, and Phil Fischer for
their review and provision of expert suggestions, and Alison Rollins for

262 www.thelancet.com Vol 381 January 19, 2013


her expert librarian services. The views expressed herein are those of the
authors, and do not necessarily reect the ocial policy or position of the
Department of the Navy, Department of Defense, or the US Government.
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