|Year : 2021 | Volume
| Issue : 1 | Page : 1-3
Urgency for pediatric critical care management in Bangladesh
Shahana Akhter Rahman, Mujammel Haque
Department of Pediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
|Date of Submission||05-Sep-2021|
|Date of Acceptance||23-Sep-2021|
|Date of Web Publication||29-Dec-2021|
Prof. Shahana Akhter Rahman
Department of Pediatrics, Bangabandhu Sheikh Mujib Medical University, Dhaka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Rahman SA, Haque M. Urgency for pediatric critical care management in Bangladesh. Paediatr Nephrol J Bangladesh 2021;6:1-3
Despite an expected reduction in infant and under-5 mortality and achievements of Millennium Development Goal 4 (MDG 4), we still have a long way to go to achieve the Sustainable Development Goal (SDG) targets by 2030. We are fortunate that among the 27 of 138 developing countries achieving MDG 4, Bangladesh is one of the leading countries and our country continues to be a role model in MDG achievement. Number 3 goal of SDG addresses good health and well-being, and the slogan is “Ensure healthy lives and promote well-being for all at all ages.” Along with reduction of maternal mortality, newborn and under-5 mortality, and infectious diseases including AIDS, tuberculosis, malaria, neglected tropical and other communicable diseases, SDG separately emphasized on non-communicable diseases, road traffic accidents, and quality of life. For achieving all these SDG goals, establishment of effective pediatric emergency and critical care medicine (PCCM) is of utmost importance. Along with other aspects including preventive care, nutritional, and medical management, establishment and development of critical care services in pediatrics can substantially reduce child mortality and improve the quality of life. Today, this is the urgent global need.
In the last few years, we have seen the havocs created by infectious diseases in the form of epidemics and pandemics. We have experienced a dengue disaster in Dhaka in 2019 and now the COVID 19 pandemic has destroyed the normal livelihood globally, with lot of mortalities and acute and chronic debilitating morbidities. In fact, COVID-19 disease has stopped the world in all aspects including education, proper health care of non-COVID patients, job security, tourism, social life, and economy. There is still uncertainty as to how long this pandemic will persist and when we will be able to return to our normal life. During the Dengue Menace 2019, among more than 700 children admitted in Bangabandhu Sheikh Mujib Medical University (BSMMU), almost half were admitted with the warning signs and around 10% of them had dengue shock syndrome. Due to a lack of effective pediatric critical care service, we faced many problems and had to struggle a lot to salvage the critically ill children with dengue shock syndrome. COVID-19 disease may be relatively rare and milder in children, but there is a global concern of the association between COVID-19 disease and multisystem inflammatory syndrome in children (MIS-C), which is a dreadful condition, and during management, these children frequently need critical care services in Pediatric Intensive Care Unit (PICU). The Department of Pediatrics, BSMMU is experiencing challenges with quite a number of children with MIS-C. Similar experiences are faced by Dhaka Shishu (Children) Hospital, Dhaka Medical College Hospital, and other institutes having Department of Pediatrics.
Even during normal (non-epidemic) times, while giving care to many sick children with septic or other types of shock, coma, acute respiratory distress syndrome, paralytic Guillain–Barré syndrome, macrophage activation syndrome, head injury, road traffic accidents, and any other pediatric emergencies, lack of effective critical care service is a big problem faced by our pediatricians. With the advancement of subspecialties in pediatrics, children with malignancies, chronic kidney diseases, congenital cardiac problems, chronic neurological, gastrointestinal, and many other critical problems are receiving intensive therapies including bone marrow, kidney, and different organ transplantations. Presence of pediatric critical care services in a proper PICU setting is a prerequisite in these situations, which would have a very positive impact on expansion of these much needed modern technology-dependent medical care services in our country.
Pediatric critical care medicine (PCCM) is a relatively new but a growing pediatric subspecialty which emerged in the 1960s and is expanding rapidly worldwide. It has been recognized as a distinct subspecialty for only about the last 3–4 decades. The history of pediatric critical care dates back to 1955, when the unit was opened in Western Sweden at the Children’s Hospital of Göteburg, 10 years prior to the PICU unit in the District of Columbia at the Children’s Hospital, which was developed by Cheston Berlin. The next documented PICU was developed by John Downes in Philadelphia Children’s Hospital in 1967. In Canada, the first PICU dedicated to older infants and children was established in the year 1971 in the Hospital for Sick Children, Toronto. Over the next 4 decades, hundreds of PICU were established in academic institutions, children’s hospitals, and many community hospitals throughout North America and Europe.
But the scenario is totally different in resource-limited countries including South Asia, the Sub-Saharan region, and most African countries. Outbreaks and pandemics like dengue, Ebola virus, and finally COVID-19 disease have highlighted the fragility of healthcare systems in these countries. Now it is high time for a paradigm shift in the global healthcare system and healthcare delivery related to critical illness.
Among the resource-limited countries, if we look at the experiences of our neighboring country India, the scenario is quite optimistic. Though pediatric-intensive care medicine in India was introduced in the 1980s, early units were simply located in a special “treatment room” and there were no facilities of constant monitoring, respiratory or hemodynamic support essential of a PICU. The first organized PICU in India was established at Kanchi Kamakoti Childs Trust Hospital in Chennai with only seven beds in 1991. A separate team of doctors and nurses were recruited and trained and the team was led by a pediatric anesthesiologist. Subsequently, there was an initiative to upgrade the pediatric critical care facilities. Primarily major teaching institutes established the formal PICU. From a single PICU in 1991 to 2021, PCCMs have come a long way. The Indian Academy of Pediatrics in the banner of “The Intensive Care Chapter” has started a formal fellowship training in 2002. Now, they have 22 accredited centers for effective training of pediatric intensivists. At present, there are more than 100 dedicated PICUs in the public and private sectors. Among the resource-limited countries, India has been a leader in respect to pediatric critical/intensive care medicine.
Coming to our country, Bangladesh, till now, intensive care or critical care medicine is an emerging but less emphasized concept here. The first intensive care unit (ICU, for adults) in Bangladesh was established in the National Institute of Cardiovascular Diseases in 1980. Currently, there are about 100 hospitals with ICU facilities in Bangladesh and 80% of them are located in Dhaka. Twenty-seven governmental hospitals have ICU facilities, which is only about 22% of the total number of ICUs. The majority of our population cannot afford the cost of private hospitals. Transportation of critically ill patients is another burning issue as most of the ICUs are located in Dhaka.
PCCM in Bangladesh is still in its early infancy. The first dedicated pediatric ICU in Bangladesh was established in 1994 in Dhaka Shishu (Children) Hospital. Now only about 11 or 12 hospitals (including both the public and private sector) are running PICU. Among them, only a few are managing their PICUs efficiently with well-trained and dedicated team members along with proper settings. The National Heart Foundation Hospital and Research Institute has the largest PICU in Dhaka under public–private partnership. It is run by pediatric intensivists, trained nurses, and other staffs. This is a well-equipped PICU having all the modern facilities. Dhaka Medical College and Combined Military Hospital, Dhaka have 6- and 12-bedded PICU, respectively, running under the supervision of Department of Pediatrics. At present, BSMMU has no dedicated PICU but two beds are available in the adult ICU for the management of critically ill older children. Very soon, a 10-bedded well-equipped dedicated PICU will be started at the Super Specialized Hospital under BSMMU.
In the private sector, only one hospital has a separate space for six-bedded PICU with modern facilities. Some other private hospitals in Dhaka and Chittagong are also providing pediatric critical care management. But most are managing pediatric patients at the adult ICU.
Pediatric intensive care specialty grew out of a need for increasingly complex postoperative management, in the face of rapid advances in surgical and medical subspecialties, and the development of sophisticated life-support technology. The intensivist directs a multidisciplinary team that includes other subspecialists, nurses, nutritionists, pharmacists, social workers, therapists, and others. The pediatric intensivist’s role is to provide supportive care during cardio-respiratory, multi-organ failure, and recovery from surgical interventions or trauma. He/she also needs to coordinate complex treatment strategy with multiple sub-specialties for further care of critically ill children. It must be remembered that critical care is to be provided to the patients who have chance of potential recovery and not for terminal care, especially in resource-limited settings like ours. It should operate with defined policies, protocols, and procedures including its own quality control, infection control, and training and research programs.
The development and establishment of pediatric critical care units are still a major challenge for us. Along with the PICU settings, we need well-trained pediatric intensivists, nurses, and other support staffs. Initially, we may need to provide formal training to our doctors abroad, if necessary. Eventually, we have to start a PCCM training/fellowship program in our own country. Some pediatricians from government and private sectors received pediatric critical care training abroad upon personal interest. The Bangladesh Pediatric Association (BPA) along with other professional associations and bodies should take the lead for the development of this essential subspecialty. And it should include: building awareness among pediatricians and policy makers, research activities, and organizing training for pediatricians and other support staffs home and abroad. We must always remember that an ideal PICU can increase the survival chances of critically ill children. We are optimistic that such steps will be taken soon and there will be a platform for independent pediatric critical care medicine specialty for better management of our critically ill children, which will also eventually lead us one step forward in achieving the SDG goals.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sustainable Development Goals. General Economic Division; Planning Commission, Ministry of Planning. Dhaka: Govt. of Bangladesh; 2018.
Rahman SA Dengue Menace 2019 Dhaka: A closer look. Bang J Child Health 2019;43:135-7.
National Health Service and Pediatric Intensive Care Society, UK. Pediatric Inflammatory Multi System Syndrome Temporarily Associated with SARS-COV-2 (PIMS-TS): Critical Care Guidance, PIMS-TS Rapid Guidance, V4, 14 May 2020.
Epstein D, Brill JE A history of pediatric critical care medicine. Pediatr Res 2005;58:987-96.
Bhalala U, Bansal A, Chugh K Advances in pediatric critical care research in India. Front Pediatr 2018;6:150.
Mostafa N Critical care medicine: Bangladesh perspective. Adv J Emerg Med 2018;2:e27.
Directorate General of Health Services—DGHS; Statement on March 31, 2015. Ministry of Health and Family Welfare; Govt. of Bangladesh.
Hussain M, Mamun MAA, Hasan NA, Rima R, Jabbar A Establishing pediatric cardiac intensive care unit in a low resource setting: Bangladesh perspective and Dhaka Shishu (Children) Hospital paediatric cardiac intensive care unit model. Bang J Child Health 2015;39:141-7.
Personal Communication (Hasan NA, National Heart Foundation Lieut. Col. Ameen, CMH, Anwer S, Dhaka Medical College).
Ministry of Health and Family Welfare, Govt. of Bangladesh. National Intensive Care Unit (ICU) Quality Improvement (QI) Framework. Dhaka: Jerin Efaz Enterprise; 2019.