Researchers have expressed concern that the new World Health Organisation approved method for treating pneumonia, Kenya’s number one child killer, could lock certain groups of sick children out of hospital care, and put them at risk of death.
In the first major revision since development almost 30 years ago, the guidelines downgraded the key physical sign previously used to identify severe pneumonia cases – in-drawn lower chest wall — as a sign of non-severe pneumonia which does not need the child to be hospitalised.
In the new guidelines, a child whose lower chest wall is indrawn will be given oral antibiotics to be taken at home, despite data that shows that death occurred in children with this characteristic symptom even in hospital.
Kenyan policy makers recognised this risk and recommended the option of hospitalising these children under the national recommendations.
Pneumonia, a disease that presents with a cough accompanied by short laboured breathing, is the leading killer in Kenya. In 2016, it claimed 21,295 lives Kenya according to data from the Ministry of Health, majority of whom were children.
KEMRI-Wellcome Trust’s Ambrose Agweyu analysed data of 16,031 children suffering from pneumonia in 14 of Kenya’s County Hospitals before the new guidelines were formally rolled out.
Five per cent of these children (832) died, and one in every four of the children that died (39 per cent), had an in-drawn lower chest, and would therefore have been classified as “not severe” under the new guidelines.
In an email interview with HealthyNation, Dr Agweyu expressed concern over WHO’s simplification of managing children with pneumonia into two categories of “low-risk” to be treated at home and “high-risk” to be hospitalised for treatment.
Dr Agweyu says that the change may make it easier to train health workers, but the data showed that some of those labelled “low-risk” actually fall somewhere between low-risk and high-risk, an “unrecognised intermediate severity”. “Under the new WHO guidance, such children would end up being sent home on oral treatment, instead of being hospitalised,” he wrote.
Despite the criticism, Dr Agweyu said that the guidelines have saved a lot of lives — pneumonia deaths have reduced significantly both globally, and in Kenya — and that the global health body is now more transparent in the manner in which it develops advice on how patients should be treated.
FEAST TRIAL STUDY
This is not the first time that the UN health body has been criticised for guidelines that did not take into account the underfunded ill-equipped hospitals in Kenya.
In 2011, the FEAST Trial study looked at how the accepted practice of giving children in shock large amounts of intravenous fluids, when their bodies start to “shut down” due to an infection, killed more of them than if they were given the fluids more slowly. WHO later revised their recommendations in updated guidelines published in 2016.
Just like the FEAST Trial, these pneumonia guidelines favoured well-equipped hospitals with advanced medical equipment that would monitor negative turns in treatment.
Most hospitals in Kenya lack ventilators, equipment that assists children with breathing difficulties. The one-blanket-fits-all approach has received criticism from paediatricians.
Dr Agweyu recommends “modifying” the guidelines to take into account the risk factors identified in his study. Further, Prof Kim Mulholland of the London School of Hygiene and Tropical Medicine was particularly concerned for Africa where deaths caused by pneumonia remains high.
“Current WHO guidelines are missing a significant proportion of the most severely ill children with pneumonia,” he wrote in The Lancet. WHO’s office had acknowledged our enquiries but had not responded to our questions by the time we went to press.