Time after time - why some children keep coming back to hospital

Why are Kenyan children more likely to become severely ill if they have recently been in hospital? A study by the Kenya Medical Research Institute and the UK University of Oxford followed nearly four thousand children from birth through their early lives when they are at most risk from fatal infectious diseases.

Malaria, diarrhoea and acute respiratory tract infections are the most common reasons for admission to hospital in Kilifi, a rural coastal district. A small proportion of children have an increased risk of severe disease and death following discharge from hospital. How can health services target those children most at risk?

For many years the international health community has focussed on improving local primary healthcare services in developing countries. By contrast, hospitals have been seen as an economic burden on limited health budgets benefiting only a small sector of the community. In 1993 the World Bank's Development Report sought to re-integrate district hospital services into broader health provision in the South. How can hospitals and primary health services work together to optimise healthcare for children?

During the 68 months of the study, nearly a third of the children in a censused community were admitted to the district hospital. After leaving hospital, nine percent were re-admitted within three months and a further 1.4 percent died at home. The large majority of children survive more than a year after leaving hospital. However, the mortality rate for children within three months of discharge from hospital is higher than for other children in the community. The risk is particularly high for those with diarrhoea, which may be due to a more serious underlying condition such as a chronic nutritional disorder or HIV infection.

Children who have been in hospital are also more likely to need to go back into hospital than others in the community. Those most at risk are likely to be children who:

• are taken from hospital before their treatment is complete
• develop complications of infectious diseases due to a genetic susceptibility to severe disease or household-specific risks
• are at continuous risk of life-threatening conditions due to congenital disorders, sickle cell disease or HIV infection.

The concept of the "at-risk child" is well recognised by health professionals in the North, and is known as the "revolving door syndrome". When considering the role of district hospitals in healthcare for children, policy-makers should:

• include this concept in new initiatives such as the integrated management of childhood illnesses
• develop strategies to identify at-risk children and produce guidelines for their treatment
• investigate the social, behavioural or nutritional risk factors associated with re-admission or fatal outcome after hospitalisation
• co-ordinate hospital and primary care services to strengthen the provision of healthcare for children.

Source(s):
‘Paediatric survival and re-admission risks following hospitalization on the Kenyan Coast’ by R. Snow et al, Tropical Medicine and International Health 5 (2000)

Funded by: The Wellcome Trust (UK); WHO TDR; Kenya Medical Research Institute

id21 Research Highlight: 25 January 2001

Further Information:
Robert Snow
KEMRI/Wellcome Trust Programme
PO Box 43630
Nairobi
Kenya

Tel: +254 2 720163
Fax: +254 2 711673
Contact the contributor: bobsnow@wtrl.or.ke

Other related links:
Read this issue of International Health Matters on child health.

The Women's and Children's Health Policy Centre at Johns Hopkins University carries out policy-related research.

Child Health Dialogue is Healthlink Worldwide's newsletter on child health and disease prevention.

UNICEF's State of the World's Children report is now on-line.