Epidemiol. Serv. Saude, Brasília, 26(1), Jan-Mar 2017
RESEARCH NOTE
Hospitalizations of Brazilian children under fiver years
old: a systematic review
Correspondence:
Dixis Figueroa Pedraza – Av. das Baraúnas, No. 351, Bairro Universitário, Campina Grande-PB, Brasil. CEP: 58429-500
E-mail: dixisfigueroa@gmail.com
Abstract
Objective: to describe the causes of hospitalization of Brazilian children under five years old. Methods: this is a systematic
review of articles published from 2008 to 2015, searched in the databases Medline and LILACS; selected studies were critically
analyzed through a validated instrument. Results: eleven articles were included, four of them are ecological and seven are
cross-sectional studies; respiratory diseases (n=5), parasitic infections (n=4) and perinatal diseases (n=2) were the main
causes for hospitalizations in the reviwed articles; in the studies that analyzed the sensitive conditions, pneumonia (n=6),
gastroenteritis (n=5), and asthma (n=5) were the mais causes pointed out. Conclusion: respiratory, parasitic and perinatal
diseases revealed to be the main causes for hospitalizations in Brazilian children; pneumonia, gastroenteritis, and asthma
constitute the most important of hospitalizations, treatable in the ambulatory health care.
Key words: Children’s Health Care; Hospitalization; Ambulatory Health Care; Literature Review as Topic.
doi: 10.5123/S1679-49742017000100018
Dixis Figueroa Pedraza
1
Erika Morganna Neves de Araujo
2
1
Universidade Estadual da Paraíba, Programa de Pós-Graduação em Saúde Pública, Campina Grande-PB, Brasil
2
Universidade Estadual da Paraíba, Mestranda do Programa de Pós-Graduação em Saúde Pública, Campina Grande-PB, Brasil
Epidemiol. Serv. Saude, Brasília, 26(1), Jan-Mar 2017
Introduction
The importance of Primary Healthcare (PHC) in
the healthcare system implies the need of continuous
evaluations of its performance.
1
In order to accomplish
this purpose, mortality and morbidity indicators may
be employed, such as the list of hospitalizations for
Ambulatory Care Sensitive Conditions (ACSC), which
takes into consideration health problems for which
the PHC can decrease the risk of hospitalization.
1,3
This indicator was proposed to evaluate the PHC,
and it considers that the rates of hospitalization can
highlight the conditions of access to and the operation
of health services.
2,4
The term ACSC-related hospitalization originated
in the United States of America in the 1990s.
Later, other countries also have shown concern
in evaluating the quality of ambulatory health care
based on avoidable hospitalizations.
5,6
In Brazil, considering the need for establishing a list
that reflects the diversity of health conditions, and of
illness in the national territory, in 2008, it was published
the official list of ACSC-related hospitalization
7
. This list
was built based on the 10
th
revision of the International
Statistical Classification of Diseases and Related Health
Problems (ICD-10).
8
The Brazilian list contains 19
groups of causes of hospitalization, and diagnostics
which gather preventable diseases by immunizations.
It also gathers infectious and chronicles diseases. Its
objective is to contribute to the evaluation of the health
system performance and of the PHC impact on the
health conditions of the population.
7,9
Considering the health care provided to the population
in general, children’s health care represents a priority
field, due to their susceptibility to illness and worsening
of illnesses as a consequence of their fragility proper
of their age.
10,11
In child population, unlike adults
population, there is a predominance of acute illnesses,
which compound part of the Brazilian list of ACSC-
related hospitalization.
7,9
Therefore, these pathologies
are avoidable with the timely assistance of the PHC
services. Especially the perinatal diseases – and the fact
they could be avoided – makes them responsible for a
large portion of the hospitalizations of children under a
year and the main cause of infant death in Brazil.
12,13
This
literature review pointed out high rates of ACSC-related
hospitalization in Brazilian children, although studies
on the subject are still incipient.
14
The research was conducted with the purpose of
obtaining answers to the following question: what is
known about the causes of hospitalization (general
causes and Ambulatory Care Sensitive Conditions) of
Brazilian children under five years old? This article
proposes the following hypothesis: the leading causes
of hospitalizations amongst Brazilian children under
the age of five are respiratory diseases and perinatal,
not sensitive to ambulatory health care. Thus, the
present study aimed to describe the causes of Brazilian
children's hospitalizations under five years old
reported in the literature.
Methods
The study is a systematic review of scientific articles
concerning the causes of general admissions, and of
ACSC-related hospitalization in children under five
years old in Brazil. The article fulfilled the PRISMA
recommendation for reporting systematic reviews and
meta-analyses.
15
Two reviewers worked independently.
The definition of conditions considered sensitive to
ambulatory health care was based on the official list
of the Ministry of Health.
7
Eligibility criteria
We considered eligible the studies about hospitalizations
published between 2008 and 2015. The choice of this
period is justified because it the publication of the list
of ACSC-related hospitalization occurred in 2008.
7
Publications in English, Spanish and Portuguese were
considered; scientific documents published in the format
of original articles and studies with Brazilian populations
which included in theirs analyses children under five
years were considered likewise.
Sources of information
The studies were identified in the databases Medline
(National Library of Medicine, Bethesda, MD) and
LILACS (Latin American and Caribbean Center on
Considering the health care provided
to the population in general, children’s
health care represents a priority
field, due to their susceptibility to
illness and worsening of illnesses as a
consequence of their fragility proper
of their age.
Hospitalizations of Brazilian children under fiver years old: a systematic review
Epidemiol. Serv. Saude, Brasília, 26(1), Jan-Mar 2017
Health Sciences Information - Bireme). The search
was held on January, 11
th
2016.
Search strategy
All the documents containing the combination of
descriptors Hospitalization AND Ambulatory Health
Care AND Child Health were considered. In Medline, the
search added the descriptor Brazil. For the calculation of
the total amount of studies identified, it was verified if any
duplication of these studies between the two databases
occurred. Each article was counted only once.
Selection of Studies
We screened the studies by reading the titles and
abstracts. This process eliminated (i) publications in
languages other than English, Spanish or Portuguese,
(ii) monographs, dissertations and theses, (iii) review
articles, (iv) studies conducted concerning other
countries other than Brazil and (v) publications that
did not include in its analysis children under the age
of five. After the screening process, of inclusion and
exclusion were applied, which involved reading the full
text, and a careful analysis of it.
In order to include publications in this review,
studies that addressed the theme of hospitalizations in
children under five years old were taken into account.
Studies that favored different age groups have been
included since there was a categorization for children
under five years, thus allowing to identify the profile of
hospitalizations for the age group of interest. Studies
that presented the following characteristics were
excluded: (i) analyzed a group of specific causes
(such as asthma and respiratory infection), without
conforming an aggregate of different types of causes,
(ii) analyzed institutionalized patients (childcare, for
example), (iii) analyzed only the admissions in specific
hospital units (intensive care unit), (iv) their analyses
were solely on economic evaluation, (v) their analyses
were solely on the effect of the improvement in access
to PHC on hospitalizations for sensitive conditions
without quoting the causes, and (vi) dealt with the
impact of programs or techniques, independent of the
PHC, on the sensitive conditions related hospitalization.
The references lists of the included articles were
analyzed in order to identify other possible studies of
interest. The selected articles, through the consultation
of bibliographical references, underwent the same
eligibility criteria, previously described. However, this
procedure did not result in the addition of articles for
the systematic review.
Data extraction
To ensure accuracy and reliability to the results of
the review, the articles identified in the databases were
grouped in folders that responded to the selection
criteria. The discrepancies of rank between the two
reviewers were resolved by consensus.
The selected information in the articles for their
characterization was the following: author and year of
publication, place, design, age group, type of data used
in the analysis, method of definition of the sensitive
disorders, hospitalizations of analysis (general and/
or primary care sensitive conditions), performance
indicators used in the analysis and main results. In
case of studies that considered several age groups,
only the results pertaining to children under the age
of five were included.
Evaluation of the quality of the included articles
The quality of studies was assessed by one of the
reviewers using the instrument of critical evaluation for
studies of prevalence developed and tested by Munn et
al.
16
This instrument consists of ten questions about the
adequacy and accuracy of the study in relation to the
validity of the methods, interpretation and applicability
of the results. Each item was evaluated with one point
when the answer was positive or 'not applicable', half
a point when the answer was uncertain, and zero when
the answer was negative, generating a maximum score
of 10 points. The score of each article was used for their
classification into three categories: high quality (8 to 10
points), medium (5 to 7 points) and low (0 to 4 points).
Data analysis
The articles were grouped according to the
hospitalizations of analysis (general and/or primary
care-sensitive conditions). For each category, the
causes of hospitalizations listed by the authors were
described, considering the first up to the sixth cause. In
the case of studies in which researchers discriminated
age groups, these categories were respected. In these
cases, the data on ambulatory care sensitive conditions
were analyzed for children under one year, from 1 up
to 4 years old and/or under the age of 5 years old. The
results were synthesized considering the leading causes
for hospitalizations and ACSC-related hospitalization.
Results
The flowchart which presents the process of
identification and selection of the studies can be found
Dixis Figueroa Pedraza and Erika Morganna Neves de Araujo
Epidemiol. Serv. Saude, Brasília, 26(1), Jan-Mar 2017
in Figure 1. Eleven articles were included,
1,2,3,11,12,17-22
,
four of them ecological
2,12,17,22
, and seven cross-
sectionals.
1,3,11,18-21
. All the included articles were
systematized, because only one of them presented an
evaluation of the average quality and none of them was
classified as low quality.
The general characterization of the studies is set in
Table 1. Virtually all studies used secondary data for
the survey of the information related to the causes of
ACSC-related hospitalization, with the exception of one.
3
Concerning the place where the studies were conducted,
two of them have a nationwide scope
17,18
, four of them
focused on the Southeastern region,
1,3,19,21
, three of them
refer to the Southern
11,12,20
region, and two of them were
held in the Northeastern region of the country.
2,22
All
studies found high rates and general admissions and/or
for sensitive conditions, especially for preventable causes.
While six studies included children’s age group
which is the focus of the present review,
2,3,11,12,20,22
two
of them worked with all age groups
1,21
and one includes
children younger than 4 years old.
18
The categorization
of the ages was considered by four studies.
1,17,19,21
The methods of definition of PHC sensitive
conditions used by the studies were the following:
the official list of the Brazilian Ministry of Health,
7
used in six studies;
1,3,12,17,21,22
ICD-10,
8
used in four
studies;
11,18-20
and both the official list
7
and the definition
of the ICD-10
8
were used in one study.
2
Regarding the
hospitalizations under analysis, three studies
12,17,22
referred only to ACSC–related hospitalization, five of
them referred to hospitalizations in general,
2,11,18-20
and three of them addressed both the ACSC–related
hospitalization and hospitalizations in general.
1,3,21
In the seven studies that addressed the admissions
in general,
1,2,3,11,18-20
their results reported the parasitic
infections in children from 0 to 4 years old or under
5,
2,3,18,20
respiratory diseases,
2,11,18-20
diseases of the
perinatal/neonatal period
2,20
and surgical causes
3,19
as
causes of the most frequent hospitalizations (Table 2).
Considering the six studies that dealt with ACSC-
related hospitalization,
1,3,12,17,21,22
results for children
from 1 to 4 years old and/or under 5 years old
reported pneumonia,
1,3,12,17,21,22
gastroenteritis,
1,12,17,21,22
asthma
3,12,17,21,22
and infections of skin and subcutaneous
tissue
3,21
as the causes of hospitalizations cited more
frequently. Three studies of them
1,17,21
discriminated
the results for children under one year old, reporting
pneumonia,
1,17,21
asthma,
17,21
gastroenteritis
1,17
and
kidney infections and urinary tract
1,21
as leading causes
for admissions (Table 3).
Figure 2 synthesizes the main causes of admissions.
It is noticeable that pneumonia and asthma appear
amongst the most frequently reported sensitive causes.
These are the respiratory diseases which represent
the leading causes amongst the general admissions.
The gastroenteritis, parasitic type diseases, were also
reported as avoidable causes of hospitalization with
expressive frequency.
Discussion
According to the systematized results, pneumonia,
gastroenteritis, and asthma were the main causes of
ACSC-related hospitalization, resembling to the results
of a previous study that pointed out higher frequencies
for the first two diseases.
14
These diseases are in sharp
decline in the country, a fact that,
12,17
added to the
finding of frequencies and/or expressive rates of ACSC-
related hospitalization in the reviewed articles, suggests
commitment to the effectiveness of PHC. This thesis is in
accordance with the results of the studies of evaluation of
the Family Health Strategy (FHS) with other approaches,
including perception of the users, especially related to
deficiencies in the assistance for children's healthcare,
to professional training, to the structure, to the process
of work and to the attributes of the PHC.
23-30
The results presented in this review showed
respiratory diseases, especially pneumonia, as
common morbidities amongst children in Brazil,
including in the context of ACSC-related hospitalization,
converging with the estimate of – held for the period
of 1998 to 2007 — respiratory diseases representing
40% of all hospitalizations in children under five.
31
Although children under five years old present greater
susceptibility to hospitalization for such illnesses as a
result of their biological vulnerability,
31
the possibility
of the timely identification of signs and symptoms of
these diseases in the context of the PHC makes that
outcome unjustifiable. Additionally, ambulatory care
has resources of low density technology to prevent
disease, which is done through immunization and
antibiotics,
32-34
avoiding hospitalization.
Despite the observed changes in morbidity and
mortality profiles of the Brazilian population in recent
decades, especially in the child’s age group,
35
the
intestinal parasitosis still constitute a public health
Hospitalizations of Brazilian children under fiver years old: a systematic review
Epidemiol. Serv. Saude, Brasília, 26(1), Jan-Mar 2017
Figure 1 – Flowchart of the phases of identification, screening process, and selection of the articles about the
causes of admissions in general and ambulatory care sensitive conditions related hospitalization of
Brazilian children under five years old, published from 2008 to 2015
Number of identified records in the databases Medline and LILACS
(n=755)
Number of duplicated records excluded
(n =41)
Number of sole records that underwent the screening process
(n=714)
Number of excluded records (n=412)
- Researches conducted in another countries (n=188)
- Monographs, dissertations and thesis (n=9)
- Review articles (n=14)
- Publications that did not include in the analysis the grou
age of children under five years old (n=201)
Number of records analyzed in order to decide their elegibility
(n=302)
Number of excluded records (n=291)
- Articles that analyzed a group of specific causes (n=135),
- Articles thatanalyzed institutionalized patients (n=18)
- Articles that analyzed only admissions in specific
hospital units (n=58)
- Articles that focused solely on economic evaluation
(n=34)
- Articles that analyzed solely the effect of the improvement
in access to PHC on hospitalizations for sensitive conditions
without quoting the causes (n=16)
- Articles that analyzed the impact of programs or
techniques, independent of the PHC, on the sensitive
conditions related hospitalization. (n=30)
Total number of records included in this review
(n =11)
Dixis Figueroa Pedraza and Erika Morganna Neves de Araujo