A retrospective review of the Pediatric Development Clinic implementation: a model to improve medical, nutritional and developmental outcomes of at-risk under-five children in rural Rwanda

Abstract

Background: As more high-risk newborns survive the neonatal period, they remain at significant medical, nutritional, and developmental risk. However, no follow-up system for early intervention exists in most developing countries. In 2014, a novel Pediatric Development Clinic (PDC) was implemented to provide comprehensive follow-up to at-risk under-five children, led by nurses and social workers in a district hospital and surrounding health centers in rural Rwanda.

Methods: At each PDC visit, children undergo clinical/nutritional assessment and caregivers participate in counseling sessions. Social assessments identify families needing additional social support. Developmental assessment is completed using Ages and Stages Questionnaires. A retrospective medical record review was conducted to evaluate the first 24 months of PDC implementation for patients enrolled between April 2014-December 2015 in rural Rwanda. Demographic and clinical characteristics of patients and their caregivers were described using frequencies and proportions. Completion of different core components of PDC visits were compared overtime using Fisher's Exact test and p-values calculated using trend analysis.

Results: 426 patients enrolled at 5 PDC sites. 54% were female, 44% were neonates and 35% were under 6 months at enrollment. Most frequent referral reasons were prematurity/low birth weight (63%) and hypoxic-ischemic encephalopathy (34%). In 24 months, 2787 PDC visits were conducted. Nurses consistently completed anthropometric measurements (age, weight, height) at all visits. Some visit components were inconsistently recorded, including adjusted age (p = 0.003), interval growth, danger sign assessment, and feeding difficulties (p < 0.001). Completion of other visit components, such as child development counseling and play/stimulation activities, were low but improved with time (p < 0.001).

Conclusions: It is feasible to implement PDCs with non-specialized providers in rural settings as we were able to enroll a diverse group of high-risk infants. We are seeing an improvement in services offered at PDCs over time and continuous quality improvement efforts are underway to strengthen current gaps. Future studies looking at the outcomes of the children benefiting from the PDC program are underway.

Keywords: High-risk newborns; early childhood development; primary care; sub-Saharan Africa; survival.

Figures

Fig. 1

Pediatric Development Clinic (PDC) Referral and Clinic Flow. Routine Clinic Flow: Different health facilities and services (a) refer all stable under-five children meeting referral criteria (b) to PDC for enrolment (c). At any PDC visit assessment, if an acute illness is identified, an immediately referral (d) for acute care is issued (e) followed by specialized care (f) if needed. When the child has been stabilized and preparing for hospital discharge (g), a referral back to continue PDC follow-up (h) is completed