In a recent article in the Lancet, authors Chaudhury et al. present the results of some important operations research on the treatment of pneumonia in children in Bangladesh. Under five mortality remains very high in many less developed countries, and pneumonia remains a major killer. Although most pneumonia likely won’t go away without significant improvements in overall levels of development, including important improvements in nutrition and sanitation, it is a condition that can be treated effectively with inexpensive antibiotics, at least on most of the cases. The IMCI guidelines currently recommend that children presenting with severe pneumonia be referred to hospitals or other higher level health facilities. The authors, however, found that even though the guidelines were being implemented in Bangladesh, the reality was that children were not actually making it to higher level facilities for treatment. They therefore suggested that all children presenting with pneumonia, whether severe or not, receive antibiotics at lower level health facilities. The authors claim that this approach led to much higher levels of appropriate treatment and even a reduction in mortality, although I am not sure if the paper is entirely well designed to generalize these results elsewhere.

But what this article does raise is the question of how these guidelines were developed in the first place. I guess when there is no good evidence to work from you start with what you think might work and then evaluate it aggressively. The guidelines are currently being evaluated in a number of trials, but much more operational/implementation of the nature of the work done in this article is needed.

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