Across the world, innovative and dedicated teams of healthcare workers are developing new pediatric critical care services to cater for the needs of critically ill children. With each new development, there are challenges, some of which are generic and some of which are locally specific.

In this edition of the Pediatric Critical Care Medicine journal, de Visser et al (1) have reviewed their experience of operation of a new PICU in Malawi. Starting in 2017, this new PICU admitted 531 patients over a period of 2 years, with an overall mortality of 28.1%. The mortality was substantially higher in neonates (88 of 167; 52.7%) versus older infants and children (61 of 364; 16.8%) (p = <0.001).

This PICU operates within the context of a tertiary referral hospital (the Queen Elizabeth Central Hospital in Blantyre), which serves a community of 5.5 million people (in a country where the median age is 16.8 yr [2]) and is the pediatric surgical referral site for the country. Malawi itself is one of the poorer countries in Africa with a gross national income of $580 (data from 2020) (3), which has to be seen in relation to the gross national income of the United States in 2019 of “$65,910” (https://worldpopulationreview.com/country-rankings/poorest-countries-in-africa) (3). Thus, half the population is within what could be regarded as the pediatric age group, and the government funding available for healthcare is of the order of $30 per capita per annum (4).

Within that context, the hospital was able to provide 25 “largely locally trained” nurses with four to six working per shift to cover a six-bed ICU. Those nurses received training from a range of people including highly experienced intensivists and nurse specialists from high-income countries. They worked under the supervision of two experienced pediatric intensivists in collaboration with a more extensive local team of anesthesiologists, pediatricians, pediatric surgeons, and anesthetic clinical officers. Substantial equipment has been made available to the unit (although details of supporting technical personnel were not available in the article). Both radiological and laboratory support services are available. However, there are constraints on specialist services such as provision of total parenteral nutrition and specialized pharmaceuticals.

It is remarkable that, from inception, procedures were put in place to collect data on patient admissions and to collate that information in a format that allowed a relatively detailed analysis of the admissions, PICU stay, and outcomes. It is unfortunate that it was not possible to collect information on patients in the hospital who may have benefitted from PICU admission but were not offered admission.

A notable feature of the study is the number of infants who were admitted to the PICU following major surgery. Pediatric surgical services across low and middle income countries and particularly Africa are extremely limited (5). As recently reviewed, pediatric surgical services are essential for the management of many congenital conditions, pediatric cancer, injuries (including burns), as well as many routine surgical conditions. The outcomes of neonatal surgery in Africa were reviewed recently (6), and although there has been improvement in outcomes over time, the mortality remains high. That review specifically highlighted the need for neonatal intensive care services to support neonatal surgery. This new PICU has provided essential support to the development of pediatric and neonatal services in the region.

It may be useful to focus on the factors that affect the effective management of conditions such as trachea-esophageal fistulae or gastroschisis. They clearly have a high mortality in the PICU in this study. Outcomes for gastroschisis in sub-Saharan African countries were reviewed in 2015 (7), showing high mortality relative to high-income countries and very limited access to total parenteral nutrition and intensive care services. Data from South Africa (8) (where intensive care and TPN were available) suggested that mortality was often related to late diagnosis and delayed referral for surgical management. In the context of maternal mortality, Thaddeus and Maine (9) highlighted the “3-delays,” or factors that: 1) delay the decision to seek care, 2) delay arrival at a health facility, and 3) delay the provision of adequate care. The health system has to focus on ensuring that conditions such as gastroschisis are correctly identified and appropriately treated initially, and that patients are referred timeously to centers for definitive care. It has been suggested that outcomes from gastroschisis might be regarded as a “bellwether” for the quality of health system care provision to neonates (10). However, it remains essential to develop PICU services such as those in Blantyre that support these endeavors. It is only when treatment centers are available that there is any point in patients being resuscitated and transferred. Therefore, the initially poor outcomes of these patients in this study may be: 1) not the consequence of failures of management at the center and 2) the start of a process through which these patients are referred earlier with more effective therapy. It is in that context that the outcomes of patients with conditions such as gastroschisis may be a useful Bellwether of the effectiveness of neonatal care within a health system (9).

It is also pertinent to focus on other recorded outcomes. For several groups of patients (including those who were admitted following surgery for malignancies), the final outcomes of their illness are likely to have been determined by factors other than the PICU stay. Prior to antiretroviral therapy, experience in South Africa (11) showed that while PICU survival for patients with HIV infection may have been acceptable, the majority of the survivors had died or disappeared from follow-up within a relatively short period of time. In more recent studies, the mortality after hospital discharge of critically patients (12) or patients with suspected sepsis (13) has been relatively high. In order to get a sense of the “value-added” from a PICU admission, it is going to be necessary to consider both medium- and long-term survivals of patients admitted to the unit.

One issue that has been highlighted in the study has been the paucity of nutritional support in the hospital. Much PICU care focuses on cardiovascular and respiratory supports (together with treatment of infection). However, it is noticeable that patients (who might usually benefit from TPN) are among those with high mortality in this study. It is not clear which factors contributed to the mortality (late diagnosis, presence of complications such as aspiration or infection prior to surgery, etc) nor is it clear what the mode of mortality was. However, a recent study of critically ill children at the same hospital in Malawi reported an extremely high rate of malnutrition (14) (particularly in children with malignancies), much of which appeared to have been underrecognized. Lack of nutritional support services may have been a substantial contributory factor to morbidity and mortality, and it will be exciting to see how development of these aspects of care might enable improved outcomes for these patients. In neonates requiring surgical intervention in the absence of TPN availability, it may be important to put increased focus on the provision of enteral nutrition (particularly with expressed breast milk), possibly with the addition of fortifiers (15).

The authors have highlighted the importance of infection in the morbidity and mortality experienced in the PICU and the need to understand the entire “pathway to care” that contributes to the development of infection in critically ill children and neonates. It is to be hoped that they have the support of the necessary microbiological, infection control, and antibiotic stewardship programs to address these issues.

This study has described an ambitious and important process, happening within the context of constrained resources, but with remarkable commitment and vision.

1. de Visser MA, Kululanga D, Chikumbanje SS, et al.; Outcome in Children Admitted to the First PICU in Malawi. Pediatr Crit Care Med. 2023; 24:473–483 2. World Economics: Malawi’s Median Age. Available at: https://www.worldeconomics.com/Demographics/Median-Age/Malawi.aspx. Accessed March 1, 2023 3. World Population Review: Poorest Countries in Africa 2023. Available at: https://worldpopulationreview.com/country-rankings/poorest-countries-in-africa. Accessed March 1, 2023 4. The World Bank: World Health Organization Global Health Expenditure Database. 2022. Available at: https://data.worldbank.org/indicator/SH.XPD.CHEX.PC.CD?locations=MW. Accessed March 3, 2023 5. Seyi-Olajide JO, Anderson JE, Kaseje N, et al.; Global Initiative for Children’s Surgery: Inclusion of children’s surgery in national surgical plans and child health programmes: The need and roadmap from global initiative for children’s surgery. Pediatr Surg Int. 2021; 37:529–537 6. Ekenze SO, Ajuzieogu OV, Nwomeh BC: Challenges of management and outcome of neonatal surgery in Africa: A systematic review. Pediatr Surg Int. 2016; 32:291–299 7. Wright NJ, Zani A, Ade-Ajayi N: Epidemiology, management and outcome of gastroschisis in sub-Saharan Africa: Results of an international survey. Afr J Paediatr Surg. 2015; 12:1–6 8. Sekabira J, Hadley GP: Gastroschisis: A third world perspective. Pediatr Surg Int. 2009; 25:327–329 9. Thaddeus S, Maine D: Too far to walk: Maternal mortality in context. Soc Sci Med. 1994; 38:1091–1110 10. Wright NJ, Sekabira J, Ade-Ajayi N: Care of infants with gastroschisis in low-resource settings. Semin Pediatr Surg. 2018; 27:321–326 11. Argent AC: Managing HIV in the PICU--the experience at the Red Cross War Memorial Children’s Hospital in Cape Town. Indian J Pediatr. 2008; 75:615–620 12. Chisti MJ, Graham SM, Duke T, et al.: Post-discharge mortality in children with severe malnutrition and pneumonia in Bangladesh. PLoS One. 2014; 9:e107663 13. Wiens MO, Pawluk S, Kissoon N, et al.: Pediatric post-discharge mortality in resource poor countries: A systematic review. PLoS One. 2013; 8:e66698 14. Chimera-Khombe B, Barcus G, Schaffner A, et al.: High prevalence, low identification and screening tools of hospital malnutrition in critically-ill patients in Malawi. Eur J Clin Nutr. 2022; 76:1158–1164 15. Kombo L, Smith J, Van Wyk L: Somatic growth of enteral-only fed extremely low birth weight infants in a resource-restricted setting. J Trop Pediatr. 2021; 67:fmaa119