New approach helps reduce deaths among children with malnutrition in low-resource communities
New research co-led by the Centre for Global Child Health at The Hospital for Sick Children (SickKids) suggests that a new tool for use in low-resource settings can save lives and reduce the need for hospital stays among children receiving outpatient treatment for malnutrition.
The collaborative research team studied more than 10,000young patients in Chad and found that for every 282 children where health-care workers used a Responses to Illness Severity Quantification (RISQ) system, they could prevent one child from dying as compared to standard care. RISQ also decreased the total number of days children spent in hospital by one-third. The results of the study were published in The Lancet Primary Care.
RISQ is adapted from an early warning system developed at SickKids to support clinical care at the bedside by providing an additional safety net for children whose conditions worsen while they are in hospital.
The initial development of RISQ was supported by a 2019 SickKids Centre for Global Child Health Catalyst Grant awarded to Dr. Nancy Dale. Seven years later, the tool has been evaluated in a large-scale international trial, with findings showing its potential to save the lives of children receiving treatment for malnutrition.
"Community-based health workers see and treat many children, need to make decisions quickly and their decisions have significant implications for families who must balance the risks and disruptions of journeying to a regional hospital ‘just in case’ or staying local with the possibility of the child’s condition deteriorating,” says Dr. Christopher Parshuram, the study’s Principal Investigator, and a Senior Scientist, Child Health Evaluative Sciences and Physician in the Paediatric Intensive Care Unit at SickKids.
"These findings are very encouraging because they point to a relatively simple outpatient tool that can be easily implemented to improve outcomes for these vulnerable young patients outside of hospitals and helping families stay in their home communities.”
Inside the RISQ system
Malnutrition continues to be a major contributor to childhood mortality in low-resource settings, including in sub-Saharan Africa, and is implicated in 40 per cent of deaths in children under five around the world. Even when malnutrition is diagnosed, it is not always obvious when a child’s condition is worsening — and some can deteriorate rapidly. This makes it critical for health workers to have reliable tools to identify those at greatest risk and intervene quickly.
Under standard care, children receiving treatment for malnutrition attend weekly outpatient appointments, where health workers monitor their recovery by measuring their upper arm circumference, checking for edema (swelling) and assessing their overall health, including blood oxygen levels. Following World Health Organization guidelines, health workers determine whether a child needs hospital care. Children continue receiving treatment until their upper arm measurements meet the program's nutritional recovery criteria for two consecutive weeks and they have no edema or other medical complications.
RISQ builds on these existing assessments by introducing a structured scoring system designed to help frontline health workers assess how sick a child is, identify those who may be seriously ill and determine whether routine care or hospital care is needed. The clinical decision-support tool was co-created by SickKids, the Alliance for International Medical Action (ALIMA) and the University of Maiduguri Teaching Hospital in Nigeria.
Rather than relying on individual clinical measurements alone, RISQ helps to guide treatment decisions by prompting health workers to record and score seven clinical measures: heart rate, respiratory rate, respiratory effort, oxygen saturation, body temperature, oxygen delivery and level of consciousness. Based on the severity of illness it identifies, RISQ then provides recommendations to the health-care workers on actions to take.
“In many communities where we work, health workers have to make important decisions about a child’s care without access to the diagnostic tests or specialist support that may be available in a hospital,” says Dr. Stanley Zlotkin, C-GCH Core Faculty Member, Senior Scientist Emeritus and co-author of the study. “RISQ is a systematic way to bring together the information health workers can collect during their assessment and use it to help guide what happens next.”
Further into the results
The system was first shown to be predictive in inpatients with malnutrition in Nigeria and then was modified for outpatient use. The new study is an evaluation of that new use, across 34 community health centers of the ALIMA program in Ngouri, Chad, half using RISQ and half using standard care.
The team found that 0.47 per cent of children died in the RISQ group as compared to 0.82 per cent in the standard-care group — and hospitalizations were also less common, occurring in 3.9 per cent of children receiving RISQ compared with six per cent receiving standard care. After learning more about the system, 85 per cent of workers said they believed RISQ could be useful in their practice and 78 per cent felt confident using the system.
“What’s particularly important is that we evaluated RISQ in community health centres where workers are predominantly nurses,” says Dr. Nancy Dale, former Centre for Global Child Health fellow, Registered Nurse and first author of the study. “The RISQ system empowers nurses by reinforcing their assessment skills and in serving as a safety net to support their clinical decision-making.”
For children with malnutrition, identifying serious illness and acting sooner could mean receiving the right care before their condition worsens, and ultimately, a better chance of survival.
“Seeing the potential for a relatively simple tool like RISQ to help health workers identify children who are seriously ill and make timely decisions about their care is incredibly encouraging,” says Parshuram. “For the whole team, this work is ultimately about giving health workers the tools they need to help efficiently and effectively care for young patients, wherever in the world they may be.”
Building on the trial's findings, ALIMA is developing and piloting an app-based version of RISQ to support implementation in similar care environments.
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The CRIMSON trial was conducted through an international collaboration involving SickKids, ALIMA, Alerte Santé, Chad's Ministry of Health and research partners from the University of N’Djamena, with funding from Enhancing Learning and Research for Humanitarian Assistance (Elrha) and a Robin Deverteuil Foundation unrestricted donation.
