Papers by Daniel Martinez Garcia
High Flow Nasal Cannula: A Future Device for Resource-Limited Pediatric Settings?
Introduction: global infant mortality has decreased dramatically with implementation of basic gui... more Introduction: global infant mortality has decreased dramatically with implementation of basic guidelines, scaling up of water and sanitation, strengthening of vaccination, and early detection and treatment of infectious diseases. However nowadays the majority of under-five year’s deaths are due to respiratory illnesses secondary to respiratory insufficiency. Advanced life support management for critically ill children in resource limited and humanitarian contexts is often non-existent. Development of more effective pediatric emergency and critical care services in developing countries has been identified as crucial to substantially reduce global mortality in young children. Methods: high flow nasal cannula (HFNC) is a new concept of heated, humidified and blended air/oxygen delivery device able to maintain a continuous distending pressure. It has been successfully implemented in adult, pediatric and transport settings of high-income countries. Although less efficacious than continuous positive airway pressure (CPAP) for severe cases of respiratory insufficiency HFNC has proven superior to O2 by nasal cannula in a number of diseases with respiratory distress syndrome. It also reduces the need for intubations, which in low-income settings equals to the death of the patient. Results: It has the advantages over CPAP of being easier for installation and maintenance, have less skin and respiratory complications and be better tolerated by the small patient with no need for sedation. In contrast to CPAP, HFNC is implemented in general wards with simpler implementation training. To this date no studies have been finalized in low-income settings, therefore costs and staff investment related to HFNC implementation is unknown.Conclusion: with the need to further improve the care of pediatric patients we advocate that implementation of HFNC in MSF projects would decrease under five mortality without representing a big burden on equipment and paramedical staff budget. Implementation protocols with proper staff and biomed training as well as further studies will be needed.
Sagwa Poisoning in Iraq: We Need to Talk About It
Erythroderma or Blistering in neonates: review from the MSF Telemedicine Platform and management in low-resource settings
Neonatal tetanus cases in Central African Republic - A neglected tragedy
INTRODUCTION: Tetanus is a vaccine preventable disease, which has a very low incidence in populat... more INTRODUCTION: Tetanus is a vaccine preventable disease, which has a very low incidence in population with immunization coverage, neonatal tetanus has a high fatality rate and poor long-term outcomes. Medecins sans frontiers, operational centre Geneva, has been supporting the pediatric department of “Hopital Universitaire de Berberati” (HRUB) since 2014. Here we describe clinical characteristics and outcomes of patients with neonatal tetanus admitted to HRUB. METHODS: retrospective data analysis. We reviewed individual patient files of all cases admitted between March 2014 and August 2017. Inclusion criteria were neonates with clinically suspected tetanus. Severity was graded according to Dakar score, which includes incubation period, period of onset, entry site, spasms, fever and tachycardia. RESULTS: out of 124 cases, detailed data was available for 106 patients. 7 cases were excluded because of their age (>28 days) and 11 cases due to insufficient clinical arguments. 42 patients (40%) came from Berberati town. There were slightly more males, n = 62 (58%). Number of reported cases increased over time: 10 in 2014, 20 in 2015, 36 in 2016 and 40 in 2017 until September. 73 cases (69%) were graded as severe according to Dakar score. 52 patients had non-assisted home birth and no maternal vaccination coverage. Case fatality was high with 63 deaths (59%). 9 neonates (8%) had a weight below 2000gr, all of them died. CONCLUSION: we described one of the largest cohorts of neonatal tetanus cases from a single hospital in Central African Republic, with high mortality. Persistence of neonatal tetanus is likely linked to very low rates of maternal tetanus immunization and low access to safe deliveries. MSF recently conducted mass tetanus vaccination targeting women in reproductive age in the area, but more attention to improved access to reproductive health is urgently needed.
The joint implementation of Point of Care Ultrasound (POCUS) & MSF Telemedicine to improve paediatric care - a model clinical training program
The Lancet Global Health, 2019
Frontiers in Pediatrics, 2019
Pediatric Early Warning Systems (PEWS) aim to identify hospitalized children at increased risk of... more Pediatric Early Warning Systems (PEWS) aim to identify hospitalized children at increased risk of deterioration by assigning a score based on vital signs and clinical status and guiding interventions using a response algorithm to improve outcomes. When implemented with quality improvement methodology, these systems have been shown to be effective in high-resource settings and have the potential to improve the care of children in humanitarian and resource-limited settings (RLS). The purpose of this review is to summarize the current evidence for use of PEWS in RLS and identify areas for further research. A review of the current PEWS literature in RLS was performed using Web of Science, PubMed, Scopus, Cumulative Index of Nursing and Allied Health Literature (CINAHL), EMBASE, Portal Regional da BVS, and TRIP Database. While there is limited research available on this topic, eight studies on the use of PEWS, or a PEWS score in a pediatric population in low-or middle-income countries were identified. Two studies assessed the clinical effect of implementation of PEWS; one reported a reduction in clinical deterioration events and the other a reduction in mortality. The remaining studies assessed the association of a PEWS score with signs of clinical deterioration or mortality without a response algorithm. Further research on the impact of PEWS implementation on inpatient care and outcomes in RLS is needed.
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Medecine et sante tropicales, 2018
Frontiers in nutrition, 2016
In humans, thiamine is a micronutrient prone to depletion that may result in severe clinical abno... more In humans, thiamine is a micronutrient prone to depletion that may result in severe clinical abnormalities. This narrative review summarizes current knowledge on thiamine deficiency (TD) and bridges the gap between pathophysiology and clinical presentation by integrating thiamine metabolism at subcellular level with its function to vital organs. The broad clinical spectrum of TD is outlined, with emphasis on conditions encountered in tropical pediatric practice. In particular, TD is associated with type B lactic acidosis and classic forms of beriberi in children, but it is often unrecognized. Other severe acute conditions are associated with hypermetabolism, inducing a functional TD. The crucial role of thiamine in infant cognitive development is also highlighted in this review, along with analysis of the potential impact of TD in refeeding syndrome during severe acute malnutrition (SAM). This review aims to increase clinical awareness of TD in tropical settings where access to diag...
International journal of health services : planning, administration, evaluation, 2016
Extreme weather events such as heat waves, extreme precipitation, and storm surges are likely to ... more Extreme weather events such as heat waves, extreme precipitation, and storm surges are likely to become more frequent and intense with climate change. Extreme weather-driven disasters (EWDDs) cause a substantial burden of childhood mortality and morbidity worldwide. We reviewed the published literature on EWDDs and their health impacts on children, and developed a conceptual model based on complex systems thinking to identify the health risks, vulnerabilities, and capacities of children in the context of EWDDs as a means of informing areas for adaptive intervention. We found that direct and indirect physical and mental impacts of EWDDs on child health are abundant and interrelate in complex ways. The literature review and modeling demonstrated the centrality of resilience at the level of the child and his or her direct environment, suggesting that mental health status may play a key role in a child's experience of numerous other health outcomes of EWDDs. EWDDs interact with envi...
Frontiers in Public Health, 2014
We conducted a retrospective analysis of all pediatric cases referred by Médecins Sans Frontières... more We conducted a retrospective analysis of all pediatric cases referred by Médecins Sans Frontières (MSF) field doctors via the MSF telemedicine system during a 4-year period from April 2010. A total of 467 pediatric cases were submitted, representing approximately 40% of all telemedicine cases. The median age of the patients was 4 years. The median response time (i.e., the interval between the case being submitted and the first response from a specialist) was 13 h (interquartile range 4-32 h). We selected a random sample of 12 pediatric cases in each of four age categories for detailed analysis by an experienced MSF pediatrician. In the 48 randomly selected cases, the mean rating for the quality of information provided by the referrer was 2.8 (on a scale from 1 = very poor to 5 = very good), and the mean rating for the appropriateness of the response was 3.3 (same scale). More than two-thirds of the responses were considered to be useful to the patient, and approximately three-quarters were considered to be useful to the medical team. The usefulness of the responses tended to be higher for the medical team than for the patient, and there was some evidence that usefulness to both groups was lower in newborns and adolescent patients. The telemedicine system allows the quality of the medical support given to medical teams in the field to be controlled objectively as there is a record of all cases and answers. Telemedicine has an important role in supporting the aims of medical humanitarian organizations such as MSF.
PLOS Global Public Health
From pandemics to war, from climate change to disasters-in humanitarian settings, children bear a... more From pandemics to war, from climate change to disasters-in humanitarian settings, children bear a disproportionate burden. Half of all deaths among children under five years occur in such settings [1]. Globally, one in six children-approximately 450 million-lived in a conflict zone in 2020 [2]. In 2021, children represented 41% of displaced people despite only comprising 30% of the population [3]. Yet, for children, the humanitarian machinery is ill-fit for purpose. Humanitarian settings often suffer from protracted violence and political and economic instability, which in turn disrupts primary care and public health services such as childhood vaccination and antenatal care. Conflict-affected countries have higher neonatal and child mortality rates, and surviving children are at risk for physical, psychological, developmental, and intergenerational consequences from early trauma . The increasingly protracted nature of conflict and prolonged displacement compound these burdens. Climate change exacerbates the frequency and intensity of extreme weather-driven disasters and emerging pandemics with catastrophic humanitarian challenges that disproportionately affect children . Despite devastating short-and long-term health and developmental consequences for children affected by crises, the humanitarian system fails to live up to their needs. The global community of professionals working in humanitarian settings lacks consensus on priorities, resource requirements, and training gaps. Our collective response to children's needs has been inadequate both by dimension and competence. This discussion aims to elevate the distinct and unmet needs of children and adolescents in humanitarian settings and to propose that these needs can best be met by the purposeful development of a new field: humanitarian paediatrics. We consider the need for a distinct field of humanitarian paediatrics to be profound. The justification for developing the field is based on the constraints of "global child health" and "humanitarian health." Global child health is broad and unspecific and, so far, has failed to adequately address the requirements of operating in humanitarian contexts. Similarly,
Lessons Learned From Helping Babies Survive in Humanitarian Settings
Pediatrics
Humanitarian crises, driven by disasters, conflict, and disease epidemics, have profound effects ... more Humanitarian crises, driven by disasters, conflict, and disease epidemics, have profound effects on society, including on people’s health and well-being. Occurrences of conflict by state and nonstate actors have increased in the last 2 decades: by the end of 2018, an estimated 41.3 million internally displaced persons and 20.4 million refugees were reported worldwide, representing a 70% increase from 2010. Although public health response for people affected by humanitarian crisis has improved in the last 2 decades, health actors have made insufficient progress in the use of evidence-based interventions to reduce neonatal mortality. Indeed, on average, conflict-affected countries report higher neonatal mortality rates and lower coverage of key maternal and newborn health interventions compared with non–conflict-affected countries. As of 2018, 55.6% of countries with the highest neonatal mortality rate (≥30 per 1000 live births) were affected by conflict and displacement. Systematic u...
Conflict and Health
Background An estimated 70.8 million people are forcibly displaced worldwide, 75% of whom are wom... more Background An estimated 70.8 million people are forcibly displaced worldwide, 75% of whom are women and children. Prioritizing a global research agenda to inform guidance, service delivery, access to and quality of services is essential to improve the survival and health of women, children and adolescents in humanitarian settings. Method A mixed-methods design was adapted from the Child Health and Nutrition Research Initiative (CHNRI) methodology to solicit priority research questions across the sexual, reproductive, maternal, newborn, child and adolescent health (SRMNCAH) domains in humanitarian settings. The first step (CHNRI) involved data collection and scoring of perceived priority questions, using a web-based survey over two rounds (first, to generate the questions and secondly, to score them). Over 1000 stakeholders from across the globe were approached; 177 took part in the first survey and 69 took part in the second. These research questions were prioritized by generating a...
Additional file 1 of Setting research priorities for sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian settings
Additional file 1: Supplementary Table A: Research Question Generation Survey (Print Screens of O... more Additional file 1: Supplementary Table A: Research Question Generation Survey (Print Screens of Online Survey). Supplementary Table B: Top Research Priority Questions Solicited (n = 280). Supplementary Table C. Distribution of RPS scores per dimension for the top TEN CHNRI research priority questions per SRMNCAH domain. Supplementary Table D. Members, Institutional Affiliations and Terms of Reference of the Technical Advisory Group.
Additional file 2 of Setting research priorities for sexual, reproductive, maternal, newborn, child and adolescent health in humanitarian settings
Additional file 2: Supplementary Material 1. Interview Guide. Supplementary Material 2. Table 1. ... more Additional file 2: Supplementary Material 1. Interview Guide. Supplementary Material 2. Table 1. Quality criteria for reporting qualitative research (COREQ) and Table 1. Domains, items, description, information in the study.
Improving multidisciplinary case discussions in humanitarian settings The MSF -HUG collaborative model
Type B Lactic Acidosis Due to Thiamine and /Or Magnesium Deficiency in Critically Ill Children
Child Refugee and Migrant Health, 2021
In 2018, 2.5 million infants died worldwide within the first month of life. Of those, 75% died wi... more In 2018, 2.5 million infants died worldwide within the first month of life. Of those, 75% died within the first week of life. Neonatal deaths represent 47% of the total deaths of children under 5 years old. This figure does not even include the additional 2.5 million annual stillbirths that occur globally . Risk of neonatal death is particularly high in refugee and migrant settings. Limited access to care, population movements, breakdown of essential medical services, safety concerns, and curfews may lead to inadequate prenatal care and unsafe deliveries. Furthermore, there may be limited treatment modalities, a lack of neonatal-friendly drug formulations and medical equipment, and minimal availability of staff skilled in newborn care. Hygiene standards are often difficult to maintain due to lack of access to soap and clean water, crowding, and shared living spaces. All of these factors, plus the inherent vulnerability of newborns, negatively influence newborn survival . Preterm birth, asphyxia, infections, and congenital birth defects are the most common causes of neonatal death. Luckily, even in low resource settings, many of these can be addressed with simple measures such as reliable prenatal and perinatal care, diligent hygiene control, thermoregulation, maintaining normal blood glucose levels, and support of breastfeeding. Through detail-oriented, conscientious neonatal care we can have a major impact on overall child mortality rates. In this chapter, we will first present you with the practical information you need to get your bearings when starting to care for newborns in refugee or migrant
Approach to paediatric care
Oxford Handbook of Humanitarian Medicine, 2019
This chapter outlines the fundamentals of providing care in humanitarian settings, including over... more This chapter outlines the fundamentals of providing care in humanitarian settings, including overall guidance to clinical care, key aspects of patient triage, and approaches for paediatrics. This chapter on the approach to paediatric care in humanitarian, conflict, or disaster setting, aims to assist the non-paediatrician presented with paediatric patients, by highlighting approaches, key insights, and guidance to help with clinical judgement and decision-making.
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Papers by Daniel Martinez Garcia