Chapter 8

Pediatric and Child Health Services

 Table Content
Section I: Introduction..............................................................................................................5
Section II: Operational Standards for paediatric and child health Services.............................6
Section III: Implementation guideline......................................................................................7
3.1. Paediatric and child health services management and organizational structure................7
3.2 Paediatric and child health services layout.........................................................................7
3.3 Paediatric and child health outpatient services...................................................................8
3.4. Pediatric and Child Health inpatient Services.................................................................10
3.5. Pediatric and Child Health Service Human Resource Requirements..............................14
3.6. Pediatric and Child Health Service Equipment and Supply Requirements.....................14
3.7. Clinical Audit and Continuous QI project.......................................................................14
References..............................................................................................................................17
Abbreviations

- CCO - Chief Clinical Officer

- ED - Executive Director

- EPI - Expanded Program on Immunization

- ETAT - Emergency Triage Assessment and Treatment

- FMOH - Federal Ministry of Health

- HR - Human Resources

- ICU - Intensive Care Unit

- IPD - Inpatient Department

- KMC - Kangaroo Mother Care

- LBW - Low Birth Weight

- NICU - Neonatal Intensive Care Unit

- OPD - Outpatient Department

- QI - Quality Improvement

- RHB - Regional Health Bureau

- SAM - Severe Acute Malnutrition

Section I: Introduction

Pediatric and child health care encompasses the physical, psychosocial, developmental, and
mental health care of children. The pediatrics component focuses on the curative aspect while
child health includes preventative components where care is provided from birth to young
adulthood as per the American Academy of Pediatrics. Most literature categorizes patients under
15 years as pediatric, however if weight exceeds 36kg they may still be considered pediatric
given their chronological age, and adult dosages should then be used.

Ideally pediatric services begin periconceptionally and continue through gestation, infancy,
childhood, adolescence and young adulthood. Though adolescence and young adulthood are
distinct phases, an upper age limit for pediatric services is not easily defined. The decision to
continue care with a pediatric provider should involve the patient, family and physician, taking
into account developmental needs and care capabilities. (Hackell, 2017), (Hackell, 2018).

The World Health Organization defines child health as "a state of physical, mental, intellectual,
social and emotional well-being and not merely the absence of disease or infirmity”. Healthy
children live in environments that provide opportunity to reach their fullest potential. Child
health services, provided by healthcare workers, enhance holistic growth and development to
attain optimal child health outcomes. A key goal is reducing preventable morbidity and mortality
across neonatal, infant, toddler, preschool, school age and adolescent groups.
Section II: Operational Standards for paediatric and child health Services

1. The Hospital has established management structure and developed job descriptions
detailing roles and responsibilities for all pediatric and child health services staff.

2. The hospital pediatric and child health services have adequate space, as per national
standards for its tier level.

3. The hospital has separate pediatric and child health inpatient and outpatient services.
4. The hospital pediatric and child health services are equipped with necessary equipment,
essential drugs and supplies as per its tier level.

5. The hospital has implement child friendly health services at pediatric and child health
services points/areas

6. The hospital regularly conducts clinical audit at pediatric and child health services and
links findings to QI projects.

7. The hospital has established separate pediatric emergency, triage, assessment and treatment
(ETAT) services.

8. The hospital has separate pediatric intensive care services with written protocols and
procedures as per the tier level.

9. The hospital provides immunization, growth monitoring, developmental assessment and

promotion services.

10. The hospital has established Neonatal Care services with trained staff.

11. The hospital has provided nutritional screening, assessment & treatment services.

12. The hospital has provided outreach pediatric and child health services.
Section III: Implementation guideline

3.1. Paediatric and child health services management and organizational

structure

Efficient patient flow requires appropriate inputs including human resources, infrastructure,
equipment, protocols and pathways. Proper design and implementation of patient flow minimizes
wait times, increases provider efficiency and satisfaction, optimizes resource utilization, and
improves quality of care. This section details inputs and processes required to ensure organized
client flow at pediatric and child health services, from first encounter at hospital reception
through to service exit.

 Pediatric and child health services should be led by a pediatrician or general practitioner
with minimum 2 years’ experience, accountable to the hospital Chief Clinical
Officer/Chief Executive Director per national standards and hospital tier level.
 The head leads and coordinates outpatient and inpatient services as detailed in this guide.

 All pediatric and child health service units have monthly, quarterly and annual plans with
adequate budget allocation.

3.2 Paediatric and child health services layout

Proper service area alignment facilitates simplified, comprehensive care delivery. Pediatric and
child health services should have good structural or functional proximity to minimize care delays
and enhance continuity. Thus, a seamless system is created where test results and supplies are
moved quickly to where needed.

Layout recommendations:

 Pediatric outpatient services should be separate from adult and include emergency
triage/treatment (ETAT) nearby.
  The service areas should be well ventilated and illuminated with adequate supplies,
guidelines/job aids, drugs and equipment per tier level.

 Spacious waiting area with seats/benches for patients/parents or caregivers.

 Play area for visiting children at waiting area and child friendly settings at all service
points.

 Pediatric & child health services clearly labelled for easily identification.

 Pediatric and child health services structurally close or functionally aligned to minimize
delays and enhance continuity..

 For safety, pediatric and child health services preferably on ground floor if building is
multi-storey.

 Room space and alignment meets national standards for service type.

3.3 Paediatric and child health outpatient services

Pediatric outpatient services are a key component, organized with emergency services included.
Hospitals should have separate pediatric and child health areas. Care starts with emergency
triage, actively categorizing patients to outpatient or emergency services. Outpatient services
primarily manage clinically stable patients not needing urgent intervention, including healthy
children visiting for immunizations, growth monitoring and promotion. Outreach identifies and
addresses common childhood illnesses through community-based prevention programs.

Outpatient care goals are providing safe, effective, comprehensive care to minimize
complications, restore health for routine activities, and prevent common childhood illnesses. Key
activities include: nutritional screening, assessment and treatment; growth monitoring, promotion
and developmental assessment; immunization services; and pediatric/child health outreach.

Nutritional screening, assessment and treatment

Early childhood is crucial for rapid brain development and establishing cognitive, language,
social and emotional growth. Ages 0-3 are most critical with 80% of brain growth by age 3.

Integrated age-appropriate developmental assessment and counseling should be provided at

outpatient visits for both sick and well child care. Facilities should have play areas to stimulate
early childhood development and strong referral linkages across health facilities and sectors

Immunization service

Immunization boosts immunity and reduces vaccine-preventable diseases across the lifespan. In
Ethiopia, the Expanded Program on Immunization (EPI) launched in 1980 with six antigens,
expanding over the years to currently provide 12 antigens routinely. EPI significantly contributes
to preventing child mortality and disability. Introduction of new vaccines such as Hep-B and Hib
(as Pentavalent vaccine) in 2007, PCV in 2011, Rotavirus Vaccine in 2013, Inactivated Polio
Vaccine (IPV) in 2015, HPV in 2018 and Measles second dose (MCV2) in 2019 were among the
greatest achievements of the program. Hospitals should have functional EPI services providing
all primary vaccines to eligible children and neonates on all working days.

Pediatric and child health outreach services

Pneumonia, diarrhea, and malaria are leading causes of under-5 mortality, preventable and
treatable with simple, low-cost interventions. Outreach care delivery through community health
workers, in collaboration with hospitals, can substantially increase coverage and reduce child
mortality. Hospitals should establish outreach services through community health workers
(CHWs) to conduct community-level childhood illness prevention and treatment.

The outreach service is a key part of the outpatient services where there is a dedicated personnel
to lead it. The outreach service starts by doing structured assessment at the community level and
additionally reviewing the data from the pediatric and child health hospital services. Activities
are planned based on identified problems and epidemiology, implemented regularly, and
reviewed quarterly against plans. Outreach service shall include assessment of nutritional status,
EPI status, developmental milestones and congenital anomalies including spinal bifida,
hydrocephalus, clubfoot, cleft lip & palate.

Pediatric Emergency care services

Hospitals should establish pediatric Emergency Triage and Treatment (ETAT) services within
pediatric outpatient areas. Rapid triage of all children categorizes cases as emergency, priority or
non-urgent for appropriate care. Children with emergency signs receive immediate stabilization
treatment in the adjacent emergency room. ETAT services should be staffed by trained
professionals using pediatric emergency protocols.

Emergency treatment room with necessary equipment and emergency drugs should be prepared
adjacent to the triage area where children with emergency signs are given emergency treatment
such as oxygen administration for children with severe respiratory distress, anticonvulsant
treatment for those children who are convulsing etc. Professionals with training in ETAT should
be assigned in the emergency and triage point of care.

A critical emergency service is Oral Rehydration Therapy (ORT). The ORT corner provides
treatment and prevents dehydration complications. The corner should be a separate area in
emergency services with supplies to manage pediatric diarrhea and dehydration, and clear patient
flow patterns for immediate care and transfer to inpatient services as needed.

3.4. Pediatric and Child Health inpatient Services

Inpatient care involves regular ward or specialty services like neonatal, pediatric ICU, and severe
acute malnutrition (SAM) care. Patients are admitted from outpatient or emergency services.
Some come via referral and enter through either pathway. Inpatient care by an interdisciplinary
team provides comprehensive assessment, stabilization and standardized treatment so patients
can return home and resume growth and development. Standardized evidence-based care
shortens stays and minimizes complications. Establishing good team dynamics and culture using
science and quality improvement is crucial.

SAM care service

A key inpatient service is caring for patients with severe acute malnutrition (SAM) following
national guidelines. Although malnutrition prevalence has declined in Ethiopia, SAM
management remains important. Children with SAM are vulnerable to infections and metabolic
issues, so the standard of care environment must address these risks. ( refer to: Government of
Ethiopia, Federal Ministry of Health. 2019. National Guideline for the Management of Acute
Malnutrition. Addis Ababa: FMOH.)

Pediatric ICU

The pediatric intensive care unit (ICU) provides continuous monitoring and care for critically ill
children. Specialized equipment and trained staff are essential to functionality. Respiratory
support capabilities must exist. Patients may be admitted directly from pediatric emergency or
transferred from inpatient services.

Regularly updating staff, supplies and equipment ensures sustainable, quality care. Following
quality improvement plans and responding to assessments is advised. (Refer: the national
guideline for general and specialized hospitals. The Minimum Standards for Specialized
Hospitals 2011)

Neonatal care services: NICU and KMC

Globally 4 million neonates die in the first 4 weeks of life annually and a similar number are
stillborn, mostly in low and middle-income countries with about half of deaths at home. Most
neonatal deaths could be prevented with simple, low-cost tools like antibiotics, sterile blades,
warmers and kangaroo care.

In Ethiopia, about 81,000 babies die every year in the first four weeks of life, about three-
quarters within the first week. This accounts for 42% of all deaths in children younger than five
years of age.

Neonatal care is critical where preterm birth and neonatal infection are high. Strategies include
leveling neonatal care based on degree of care capabilities. Major components are establishing
NICU care and Kangaroo Mother Care (KMC) services. NICU capabilities depend on the
healthcare tier level and follow standards to care for sick and critical newborns accordingly.

NICU care service

Neonatal intensive care units (NICUs) provide advanced technology and specialized care for
critically ill or preterm newborns. Facilities without NICU capabilities must transfer babies
needing intensive care. Outcomes improve if high-risk babies are born at hospitals with NICUs
instead of being moved after birth. .

The neonatal intensive care unit (NICU) is established with the standards set by the national
guideline as the tier level of the hospitals. Each hospital is supposed to give the neonatal care
service as a spectrum of care and cascade the transfer of neonates to advanced settings when
needed. The NICU is preferred to be organized with a close proximity to the delivery room or
have a functional proximity to transfer the neonates in a thermo neutral environment.

The functional capabilities of facilities that provide inpatient care for newborn infants are
classified uniformly, as follows:

Level I (basic): Staff and equipment for neonatal resuscitation, care of healthy newborns, and
stabilizing pre-35 week or ill infants until transfer. All hospitals should have this capability.
Level II (specialty): Care for >32 week gestation and >1500g infants with issues like apnea,
temperature/feeding instability, or short-term moderate illness not requiring subspecialists.

Level III (subspecialty): Continuous life support and care for extremely preterm and critically
ill infants, plus advanced medical and surgical care options. Specialized hospitals should have
this level of care.

District hospitals in Ethiopia are expected to have at least Level I, regional hospitals Level II,
and specialized teaching hospitals Level III NICU capabilities.

Kangaroo Mother Care

Kangaroo Mother Care (KMC) is an integral part of the neonatal care services which is
structured to provide care for low birth weight babies .This includes early, prolonged and
continuous skin-to-skin contact with the mother (or any caregiver) and exclusive and frequent
breastfeeding (optimal feeding). This natural form of humane care stabilizes body temperature,
promotes breastfeeding and prevents infection. KMC is initiated in the hospital and continued at
home as long as the baby needs it. KMC must not be confused with routine early skin-to-skin
care at birth. The World Health Organization (WHO) recommends skin-to-skin care immediately
after birth for every newborn to ensure that all babies stay warm in the first hours of life helps in
early initiation of breastfeeding. This intervention for all newborns, irrespective of weight,
promotes newborn transition and promotes exclusive breastfeeding.

For stable babies, KMC is nearly equivalent to incubator care in terms of safety and thermal
protection. Studies have shown that KMC cared LBW infants could be discharged from the
hospital earlier than the conventionally managed babies. The babies gain more weight on KMC
than on conventional care. Babies receiving KMC have more regular breathing and fewer
predispositions to apnea. KMC protects against nosocomial infections. Even after discharge from
the hospital, the morbidity amongst babies managed by KMC is less. KMC is associated with
reduced incidence of severe illness including pneumonia during infancy. Studies have shown that
KMC leads to a significant reduction of neonatal mortality when compared to conventionally
cared babies.
Health benefit of KMC to babies and emotional satisfaction to mothers helps in its scaling up in
health facilities. KMC does not require extra staff or expensive articles. It can be provided by
anyone (who is motivated), anywhere and anytime. Researches show effective thermal control,
increased breastfeeding rates, early discharge, decreased neonatal mortality, less morbidity such
as apnea and infection, less stress, and better infant bonding. KMC satisfies all five senses of the
baby; feels mother's warmth through skin-to-skin contact (touch), listens to mother's voice and
heartbeat (hearing), sucks breast milk (taste), has eye contact with mother (vision) and smells.
Hospitals should therefore have KMC service area in close proximity to the NICU which is
accompanied by a separate area for mothers’ to rest and breast feed.

3.5. Pediatric and Child Health Service Human Resource Requirements

Hospital pediatric and child health services should be staffed with pediatricians, general
practitioners, trained nurses, health officers and paramedical staff as required. Details depend on
the hospital tier level aligned with Ethiopian standards agency 2012 hospital level standards.

3.6. Pediatric and Child Health Service Equipment and Supply Requirements
Pediatric and child health services provide comprehensive care for children from birth through
age 14 years (per national standard). Medical equipment and supplies are essential for quality
care and depend on hospital tier level.

3.7. Clinical Audit and Continuous QI project

Clinical audit is a quality improvement process reviewing care against explicit criteria to identify
areas for improvement and confirm progress through change implementation and monitoring.

 The hospital shall conduct regular/quarterly clinical audit, analyze the finding and
develop QI project for the pediatric and child health services.

 The quality unit of the hospital monitors the graduation of QI projects according to its
schedule.
 All the clinical audit findings shall be communicated to the concerned decision makers
and providers.
.

References

Addisse, M. (2003) ‘Maternal and Child Health Care’, (January).

Hackell, J. M. (2017) ‘Age Limit of Pediatrics (American Academy of Pediatrics)’, 140(3), pp.
3–5.
Hackell, J. M. (2018) ‘Age Limit of Pediatrics’, (August 2017). doi: 10.1542/peds.2017-2151.
Health, Y. R. (2004) Adolescent and Youth Reproductive Health.
WHO (2002) ‘Adolescent friendly Health Services’.
WHO (2007) ‘Child Health - Definition Health workgroup, First things first’, pp. 1–2.
WHO (2013) ‘Guidelines For The Management Of Common Childhood Illnesses’.