Acute generalized peritonitis in children: A 7-year retrospective study of epidemiological, clinical, and therapeutic profiles in southeastern Morocco and 2-year forecast

Abstract

BACKGROUND:

Acute generalized peritonitis (AGP) is a life-threatening condition that demands rapid diagnosis and treatment, especially in pediatric patients. However, limited literature is available regarding its epidemiological, clinical, and therapeutic aspects in under-served areas of Morocco, particularly in Southeast provinces. Therefore, this study aims to examine the epidemiological characteristics, clinical and paraclinical presentations, and management of acute generalized peritonitis (AGP) in children aged 0-15 years from 2017 to 2023 with a 2-year forecast.

MATERIALS AND METHODS:

This retrospective study included 115 patients with AGP. Data analysis was conducted using the Chi-square test. Furthermore, the Holt-Winters method was used to forecast the AGP cases from January 2024 to December 2025.

RESULTS:

The majority (71.30%) were aged 8-15 years, with a male predominance (65.22%). The most frequent clinical features included fever and abdominal pain (100%) and abdominal guarding (87.83%). Appendicular peritonitis was the most common intraoperative diagnosis (86.09%). Surgical interventions included drainage (100%) and appendectomy (96.52%), with 86.09% of surgeries performed within 24 h. Postoperative complications were rare (4.35%), with septic shock (3.48%) being the most severe. Furthermore, the Holt-Winters model predicts continued variability of trend and seasonality of AGP cases in the upcoming years.

CONCLUSIONS:

According to the results of this study, timely surgical management and effective antibiotic therapy were critical for positive outcomes. In addition, the prediction results showed a similar pattern to the actual data concluding that the proposed model can be used to forecast the future cases of AGP in this area.

Introduction

Peritonitis is a serious and potentially life-threatening condition marked by inflammation or infection of the peritoneum. It can be generalized, affecting the entire abdominal cavity, or localized to a specific quadrant.[1,2] Peritonitis is classified into three types: primary, secondary, and tertiary,[3,4] with secondary peritonitis being the most common.[5] Typically caused by bacterial invasion or chemical irritation of the peritoneal cavity.[6,7] It is a frequent surgical condition in children, requiring hospitalization and urgent therapeutic intervention to prevent life-threatening complications.[8] While its incidence has significantly decreased in developed countries, peritonitis remains a major public health concern in developing nations.[9,10,11]

Globally, peritonitis is a critical medical emergency associated with high mortality and morbidity rates,[12] with a particularly significant impact in Africa. In Guinea, it ranks third among abdominal surgical emergencies, after appendicitis and intestinal obstruction.[8] Its prevalence has been reported at 28.1% in Congo and 49% in Niger, with associated mortality and morbidity rates of 20.98% and 49%, respectively. In Rwanda, peritonitis is the leading complication of intestinal obstruction, representing 39% of cases, followed by appendicitis at 17%. Among 280 patients diagnosed, the in-hospital mortality rate was 17%.[11] These statistics highlight the diagnostic and therapeutic challenges involved. A favorable prognosis can be achieved with a prompt and multidisciplinary approach, encompassing early detection, emergency exploratory surgery, and timely, tailored resuscitation measures. Such measures are critical to reducing the high mortality and morbidity rates in developing countries.[8,12] Prognosis also depends on factors such as the patient’s age, the underlying cause, and the time elapsed before diagnosis.[8]

The treatment of peritonitis requires both medical and surgical interventions, including resuscitation and antibiotic therapy.[13,14] Laparoscopy now plays a key role in both diagnosing and managing peritonitis.[2,15] Peritonitis can result in circulatory failure, leading to hemodynamic shock due to the development of third-spacing fluid loss.[14,16] It also induces a septic state marked by metabolic acidosis, eventually causing multiorgan failure and paralytic ileus, exacerbated by the production of bacterial toxins.[17] This condition is even more severe in children, who face additional challenges related to adapting to postnatal life and the stress of childhood.[18,19]

It has been emphasized that understanding the most vulnerable age groups and identifying patients with primary conditions at the highest risk, as well as recognizing the specific etiology of peritonitis in a given center, can significantly improve the speed of diagnosis and the timely initiation of appropriate prophylactic or therapeutic measures.[20,21] This approach is crucial for reducing mortality and morbidity, especially in resource-limited developing countries where acute generalized peritonitis is prevalent.[22] Despite being a significant and complex public health issue, there is limited research on infant and childhood peritonitis in Morocco.[23]

In addition, accurate and timely prediction of disease occurrence is of great significance for the prevention and treatment of AGP. Time series models, such as Holt-Winters, are valuable tools for disease prediction due to its ability to effectively manage both seasonality and trends in time series data, providing accurate forecasts with low computational overhead.[24,25] To the best of our knowledge, this is the first study to establish the Holt-Winters method for forecasting monthly CL cases of AGP and to analyze AGP’s characteristics in Morocco.

Therefore, the present study was conducted to analyze AGP’s epidemiological characteristics, describe clinical and paraclinical features, identify common causes, outline therapeutic strategies, evaluate postoperative outcomes, assess the effectiveness of current management practices, and predict the number of cases per month, offering valuable insights into this neglected area of research [Figure 1].

Figure 1.

Flow chart of the study

Materials and Methods

Study design and setting

The current study was a retrospective study of 115 cases of patients from the provinces of Ouarzazate, Tinghir, and Zagora in Southeast Morocco who were referred to the Provincial Hospital Center (PHC) in Ouarzazate for treatment and follow-up from 2017 to 2023. The geographic origins of patients in this study are shown in Figure 2.

Figure 2.

Geographic origins of the patients who are referred to PHC over the study period

Study participants and sampling

The study population consisted of all patients admitted to the pediatric surgery department for the 7-year study period. This sample was inclusive, encompassing all individuals who had a confirmed diagnosis of peritonitis and underwent surgical intervention, provided their medical records were complete and accessible. Patients who had laparotomy for peritonitis but were excluded due to incomplete medical records or were older than 15 years were not included in the study. This approach ensured a focused analysis on pediatric patients whose data was comprehensive and relevant to the study’s objectives.

Data collection tool and technique

Epidemiological, clinical, paraclinical, therapeutic, and outcome data were systematically collected using an Excel spreadsheet, sourced from medical records, emergency department archives, operating room logs, intensive care unit records, and postoperative reports. A total of 115 patients were included in the study, determined through a thorough review of their medical records.

Ethical consideration

Approval for this study was obtained from the relevant administrative and health authorities, Ministry of Health, Morocco [Approval No. 320/SAE/05/2024 dated January 29, 2024]. Moreover, strict measures were implemented to guarantee the confidentiality and anonymity of the data patients. The data collected throughout the study were used exclusively to assess the current state of acute peritonitis and to formulate recommendations for improving its management and treatment in Morocco.

Statistical analysis

The data extracted from the records were entered in Microsoft Office Excel and analyzed by using the Statistical Package for Social Sciences (SPSS; Release 25.0, SPSS Inc., Chicago, IL, USA). Descriptive statistics were used to describe frequencies and percentages of sociodemographic characteristics. Continuous data were expressed as mean and standard deviation (SD), whereas categorical data were analyzed using the Chi-square test, with a P ≤ 0.05 regarded as statistically significant. Prediction analysis was conducted using the Holt-Winters method. The proposed forecasting model was performed with Python version 3.11.9. The overall modeling process of this model is depicted in Figure 1.

Results

Epidemiological aspects

During the period (January 2017 to December 2023), 115 cases of acute generalized peritonitis were diagnosed, representing 21.38% of 538 gastrointestinal surgical emergencies. The highest number of cases was reported in 2020 with 28 cases, while the lowest, with 2 cases, was observed in 2021 [Table 1]. The majority of cases occurred in the age group of 8 to 15 years, which accounted for 82 cases (71.30%), followed by the age group of 3 to 7 years with 32 cases (27.83%), and those under 3 years, with 1 case (0.87%). The study population consisted of 75 males (65.22%) and 40 females (34.78%), resulting in a sex ratio M:F of 1.88:1. In terms of residence, the majority of patients, 75 individuals (65.2%), were natives of Ouarzazate. Nearly all patients reported no medical history (96.52%) or prior surgical history (99.13%). The findings also indicate that acute peritonitis was more common in summer (n = 48, 41.74%) than in other seasons [Table 1].

Table 1.

Sociodemographic characteristics and clinical history of the studied population

Variables		Absolute frequency (n)		Relative frequency (%)
Age groups (years)
Infant [≤2]		1		0.87
Children age 3−7 years		32		27.83
Children age 8−15 years		82		71.3
Gender
Male		75		65.22
Female		40		34.78
Province
Ouarzazate		75		65.22
Zagora		26		22.61
Tinghir		14		12.17
Medical history
Intermittent vomiting for 2 years		1		0.87
Gastritis		3		2.61
No history		111		96.52
Surgical history
Suppurative appendicitis		1		0.87
No history		114		99.13
Distribution of patients (Saison)
Autumn		21		18.26
Summer		48		41.74
Winter		22		19.13
Spring		24		20.87

Table 2 presents the clinical signs observed in the studied population. General symptoms indicate that all patients experienced fever (n = 115, 100%), abdominal pain (n = 115, 100%), and vomiting (n = 99, 86.09%) were the most frequently reported functional symptoms. Regarding physical signs, pain upon palpation (n = 115, 100%) and abdominal guarding (n = 101, 87.83%) were the most commonly noted. The majority of patients exhibited significant hyperleukocytosis (n = 82, 71.30%), followed by those with normal leukocyte (n = 15, 13.04%) and moderate hyperleukocytosis (n = 13, 11.31%). Only 7 cases (6.09%) showed anemia based on hemoglobin levels. C-reactive protein (CRP) testing was conducted in 22 patients, all of whom had levels exceeding the normal threshold, with values above 6 mg/L [Table 3].

Table 2.

Clinical signs of the studied population

		Absolute frequency (n)		Relative frequency (%)
Signs
Polypnea		1		0.86
Fever		115		100
General signs
Dehydration		2		1.73
AEG		16		13.91
Hypotonia		2		1.74
Constipation		1		0.87
Abdominal pain		115		100
Functional signs
Vomiting		99		86.09
Ileus		18		15.65
Diarrhea		2		1.74
Pain on palpation		115		100
Physical signs
Abdominal defense		101		87.83
Abdominal tenderness		21		18.26
Abdominal contracture		2		1.74
Abdominal mass		1		0.87

Table 3.

Biological tests (complete blood count, CRP, and renal function tests) of the studied population

Biological tests		Absolute frequency (n)		Relative frequency (%)
Number of leukocytosis per mm3
Mild hyperleukocytosis: ≤11000		5		4.35
Moderate hyperleukocytosis: >11001-14000		13		11.31
Major hyperleukocytosis: >14000		82		71.30
Normal		15		13.04
Hemoglobin level
Anemia		7		6.09
Normal		108		93.91
C-reactive protein (mg/L)
10 to 100		9		7.83
101 to 200		12		10.43
300 to 400		1		0.87
Not done		93		80.87

Table 4 outlines the paraclinical examinations conducted on the studied population. Abdominal ultrasound revealed that appendicular peritonitis was the most common finding, observed in 41 cases (35.65%), followed by fluid effusion in 26 cases (22.61%). The abdominal X-ray without preparation (ASP) indicated that the most frequent finding was a hydro-aeric level in 16 cases (13.91%). Additionally, abdominal CT scans were not performed in 95.65% of the patients.

Table 4.

Paraclinical examinations of the studied population

Modalities		Absolute frequency (n)		Relative frequency (%)
Abdominal ultrasound
Appendicular peritonitis		41		35.65
Fluid effusion		26		22.61
Appendiceal abscess		13		11.31
Peritonitis		12		10.43
Acute appendicitis		12		10.43
Complicated appendicitis		1		0.87
Not done		10		8.70
Plain abdominal X-ray
Hydro-aeric levels		16		13.91
Bowel distension		3		2.61
Pneumoperitoneum		2		1.74
Diffuse haziness		1		0.87
Normal		1		0.87
Not done		92		80.00

Preoperative and per-operative diagnosis

The preoperative diagnosis indicated that acute peritonitis was the most commonly observed condition, with 76 cases (66.09%), followed by acute appendicitis, which had 29 cases (25.22%). In contrast, the intraoperative diagnosis revealed that appendicular peritonitis was the most prevalent finding, accounting for 99 cases (86.09%) [Table 5].

Table 5.

Preoperative and per-operative diagnoses of the studied population

Diagnosis		Absolute frequency (n)		Relative frequency (%)
Preoperative
Acute peritonitis		76		66.09
Acute appendicitis		29		25.22
Appendiceal abscess		6		5.22
Intestinal obstruction		3		2.61
Acute peritonitis with intestinal obstruction		1		0.87
Per-operative
Appendicular peritonitis		99		86.09
Appendiceal peritonitis after occlusion of the appendix orifice		5		4.35
Pelvic peritonitis		3		2.61
Appendicular peritonitis on perforated Meckel’s diverticulum		2		1.74
Neglected peritonitis with sepsis		2		1.74
Severe sepsis		2		1.74
Intestinal necrosis		1		0.87
Stercoral peritonitis		1		0.87

Management of the patients with acute peritonitis

All patients with acute peritonitis received analgesic treatment, followed by triple therapy in 110 cases (95.65%). In terms of surgical interventions, drainage (n = 115, 100%), washing (n = 113, 98.26%), and appendectomy (n = 111, 96.52%) were the most commonly performed procedures. Most patients (99 cases, 86.09%) underwent surgery within 24 h, while 16 cases (13.91%) experienced a delay of more than 24 h [Table 6].

Table 6.

Treatment and medical care of patients with acute peritonitis

Treatment		Absolute frequency (n)		Relative frequency (%)
Medical
Analgesic		115		100
Triple therapy		110		95.65
Bitherapy		3		2.61
Monotherapy		2		1.74
Surgical
Drainage		115		100
Washing		113		98.26
Appendectomy		111		96.52
Diverticulum resection		2		1.74
Time before surgical management (h)
≤24		99		86.09
>24		16		13.91

The majority of patients experienced no postoperative complications, with 110 cases (95.65%). Postoperative complications occurred in 4 cases (3.48%) involving septic shock, and 1 case (0.87%) of evisceration [Table 7].

Table 7.

Postoperative complications in patients operated on for acute peritonitis

Complications		Absolute frequency (n)		Relative frequency (%)
Postoperative course
Simple		110		95.65
Septic shock		4		3.48
Evisceration		1		0.87

Correlation between characteristics of the study population and gender

The relationship between various variables (age, complete blood count, etc.) and the sex of the studied population is presented in Table 8. No significant associations were found between sex and factors such as age, mode of admission, complete blood count, or medical and surgical history (P > 0.05).

Table 8.

Relation between the studied variables and sex of the patients

Variables		Sex				Test χ2		P
		Male		Female
Age
Infant [≤2]		0		1		2.10		0.3
Children age 3−7 years		20		12
Children age 8−15 years		55		27
Mode of admission
Emergency		51		31		1.84		0.3
Referred		2		0
Scheduled		22		9
Complete blood count (leukocytes)
Mild hyperleukocytosis		9		4		2.77		0.4
Moderate hyperleukocytosis		2		3
Major hyperleukocytosis		56		26
Normal		8		7
Medical history
Nothing to report		77		36		2.4		0.2
Intermittent episode of vomiting for 2 years		1		0
Gastritis		1		0
Surgical history
Nothing to report		74		40		538		0.4
Suppurative appendicitis		1		0

Prediction model

According to the Holt-Winters (HW) model, a seasonal variation in the number of cases per month was noted. Indeed, the forecast model predicts continued variability of trend and seasonality of AGP cases in the upcoming years. Overall, the prediction estimates around 15 cases for each of the following 2 years. The analysis result of the proposed model is depicted in Figure 3.

Figure 3.

Holt-winters forecasted values of AGP cases 2024-2026

Discussion

This 7-year study, conducted in Morocco’s Ouarzazate province, aims to examine the epidemiological characteristics of acute generalized peritonitis in children aged 0-15 years. The study describes also the clinical and paraclinical features, identifies common causes, and evaluates the effectiveness of current management practices.

In this study, acute generalized peritonitis accounted for 21.38% of gastrointestinal surgical emergencies, a rate significantly higher than the 9.8% reported nationally by Azgaou[5] in the Marrakech region This elevated rate can likely be explained by the high prevalence of infectious diseases and delayed consultations in the area. Comparatively, the rate observed in this study is lower than the 37% reported in Mali, and the 39% of cases diagnosed with peritonitis in Rwanda.[5] In sub-Saharan Africa, the high prevalence of infectious diseases, particularly typhoid,[26] combined with delayed diagnoses,[27] contributes to the increased occurrence of peritonitis. A male predominance in acute generalized peritonitis has been widely reported,[9,28,29,30,31] as observed in our study with a male-to-female ratio of 9.9. Acute generalized peritonitis primarily affects children, with an average age of around 11 years reported by Osifo et al.[30] and Sambo et al.[32] Similarly, in our findings, 71.30% of cases occurred in the 8-15-year age group. Additionally, we observed a significant rise in acute peritonitis cases during the summer, likely due to various etiological and epidemiological factors. Bacterial infections, such as pneumococci and staphylococci, tend to be more prevalent during this season, contributing to the increase in peritonitis cases.[22,33,34] Children are particularly exposed to infectious agents in the summer, especially when hygiene practices are not followed,[35] heightening the risk of infection and subsequent peritonitis. Moreover, seasonal climate changes can compromise children’s immune systems, making them more vulnerable to infections, including those that lead to peritonitis.[36] Our study also revealed a decrease in cases in 2020, which may be attributed to the enhanced preventive measures implemented during the COVID-19 pandemic, such as stricter hygiene practices, reducing the transmission of infections responsible for peritonitis. Additionally, improved access to healthcare may have facilitated early detection and prompt management of conditions that could cause peritonitis. This observation contrasts with the findings of other researchers, who suggest that the decline in cases could be linked to the impact of the COVID-19 pandemic on the availability of surgical interventions.[37]

Fever was the most common general sign observed in our patients, with the rapid onset of signs like fever generally indicating the severity of the infection. These findings align with other studies, which also reported fever in all patients.[8,9] Among the functional signs, the results showed that intense, continuous abdominal pain with a sudden onset was the most frequent symptom, present in 100% of cases. This is consistent with findings from previous studies,[8] where abdominal pain was the most prevalent symptom. Regarding physical signs, pain on palpation and abdominal defense were commonly observed in our study, either localized in the early stages or generalized in more advanced stages. These results differ from other studies, which reported that pain on palpation and abdominal defense were observed in milder cases.[38] This variation may be attributed to differences in the underlying causes of peritonitis or delays in seeking medical attention. Regarding biological signs, an urgent complete blood count (CBC) was performed for all patients. Our study revealed that 71.3% of patients had elevated leukocytosis, confirming the observations of Coulibaly et al. (2013), who noted that hyperleukocytosis does not exclude a diagnosis of peritonitis. Additionally, 6.1% of patients were diagnosed with inflammatory anemia. Only 19.2% of patients underwent C-reactive protein (CRP) testing, and in all cases, CRP levels were elevated (>6 mg/L), indicating an inflammatory syndrome. However, CRP lacks specificity in determining the cause of inflammation, and self-medication with antibiotics can quickly reduce CRP levels without addressing the underlying issue.

Our findings show that acute peritonitis accounted for 66.09% of visceral surgical emergencies, making it the leading cause of such emergencies. This rate is higher to those reported by Azgaou[5] in Morocco, Engbang et al.[29] in Cameroon, Togo et al.[39] in Mali, and Ouangré[40] in Burkina Faso, where acute peritonitis represented 32.7%, 31.2%, 33.1%, and 34.9% of visceral surgical emergencies, respectively. Several studies also identify peritonitis as a primary indication for digestive surgery.[32,41] Similar rates were reported in other series, such as those by Harouna[42] in Niger (54.5%), Sambo et al.[32] in Benin (66.2%), and Kambiré et al.[43] in Burkina Faso (43.14%). These differences may be due to delayed consultation and diagnosis, as well as insufficient early management of the underlying conditions.

In this study, laparotomy with an incision around the umbilicus was performed on all patients. The most common surgical procedure was appendectomy, followed by diverticulum resection. All patients received peritoneal irrigation and drain placement, given that peritonitis due to appendix perforation was the primary cause of the pathology. These results align with those of Keita et al. (2023)[8] and Podda et al.,[44] who also found appendectomy to be the most frequently performed procedure. Medical treatment had a significant impact on the severity and survival of acute peritonitis cases.[14] In our study, triple therapy—ceftriaxone, metronidazole, and gentamicin—was the most commonly administered treatment, while dual therapy with amoxicillin and clavulanic acid was used less frequently, covering only 2.6% of cases. These findings align with Godefroy et al.,[45] who observed that treatment for secondary peritonitis in Uganda commonly involved Imipenem (88.8%), Amikacin (88.8%), Ciprofloxacin (44.4%), and Gentamicin (44.4%), all of which effectively improved patient health outcomes in cases of secondary peritonitis. For managing fever and pain pre- and postsurgery, analgesics (paracetamol, perfalgan) were the primary choice, often combined with proton pump inhibitors, antiemetics, or anti-inflammatories.

The surgical management of patients in our study shows a notable trend: nearly all (86.09%) received timely surgical intervention, while 13.91% experienced delays. These delays were primarily due to patients’ limited financial resources, which required additional testing, as well as patients’ poor general condition, which prevented immediate surgery.[46] Other contributing factors included the unavailability of blood products, limited medical personnel or surgical equipment, and inconsistent adherence to emergency care policies, which require rapid response. In our study, 95.6% of patients (110 out of 115) experienced uncomplicated postoperative recovery, while 4.34% (five patients) developed complications. These included one case of evisceration and four cases of septic shock, likely linked to postoperative peritonitis despite the appendicular peritonitis intervention.

The findings of our study are rooted in the specific context of Ouarzazate, Morocco, a region characterized by limited resources and a high prevalence of appendicular peritonitis. While some results, such as the critical importance of early diagnosis and timely surgical intervention, are universally applicable, the transferability of findings to other populations may be influenced by variations in healthcare access, socioeconomic conditions, and the prevalence of other causes of peritonitis, such as gastroduodenal perforations. These differences highlight the need for tailored management protocols based on local epidemiological profiles. To enhance outcomes and prevent complications, community-based measures should include awareness campaigns and educational events to sensitize the population. These initiatives can teach parents and caregivers to recognize early symptoms of acute peritonitis and stress the importance of immediate medical care. Collaborations with schools, local healthcare centers, and community leaders can amplify these efforts, while integrating them into public health programs can promote a proactive approach to early detection and treatment, ensuring broader applicability and improved outcomes.

Given these data, another goal is to forecast the monthly cases of AGP using the Holt-Winters method. To evaluate the prediction performance of the HW model, the predicted values from the model were compared against the actual AGP cases during the 84 months. By comparing the predicted and actual data, the proposed model has proven to be very effective in predicting future AGP cases in the aforementioned Provinces.

Strengths, limitations and recommendations

Strengths

This study addresses a critical gap by focusing on acute generalized peritonitis (AGP) in children from an under-served region, providing valuable insights into its epidemiological, clinical, and therapeutic aspects. The 6-year sample of 115 patients highlights the importance of timely surgical intervention, reflected in low complication rates. The findings offer practical recommendations for improving care in resource-limited settings.

Limitations and recommendation

Despite its valuable contributions, the study has several limitations. Disorganization within the archival system has led to the loss of some medical records, potentially introducing selection bias. Additionally, the study does not address socioeconomic and systemic barriers that could significantly impact patient outcomes and access to care, limiting a comprehensive understanding of AGP management in resource-constrained settings. Improved medical record-keeping, multicenter studies, and prospective data collection are needed to enhance reliability and generalizability. Including systemic and socioeconomic factors would provide a broader understanding of AGP outcomes in resource-limited settings.

Conclusion

Effective management of AGP requires timely surgical intervention, antibiotic therapy, and a multidisciplinary approach, though diagnosis remains primarily clinical, supported by basic tests and imaging. Early detection and prevention are essential, particularly for cases stemming from organ perforations like gastroduodenal ulcers. To address these challenges, an educational plan is crucial, focusing on enhancing the diagnostic and surgical skills of healthcare professionals. This plan should include regular training sessions on early recognition of AGP symptoms, practical workshops on refining surgical techniques, and interdisciplinary simulations to improve decision-making under resource constraints. Educational outreach should also target caregivers and the community, with campaigns to raise awareness of early warning signs and the importance of prompt medical attention. Additionally, healthcare workers should be trained on postoperative care protocols to minimize complications. The educational plan should align with national and international health policy benchmarks, ensuring that local practices meet established standards for pediatric surgical emergencies. The prediction model developed in the study can serve as a tool to accurately forecast future AGP cases. Future research should assess long-term outcomes, regional disparities, cost-effectiveness, and the impact of public awareness while advancing diagnostic tools and developing pediatric-specific guidelines to improve outcomes in resource-limited settings.

Conflicts of interest

The authors declare that there are no conflicts of interest.

Funding Statement

No applicable.