Keywords

1 Introduction

Significant achievements and new emerging challenges have been observed in child healthcare in the world over the last decades. In most countries including low- and middle-income countries (LMICs), child mortality rates have gradually decreased. According to the latest estimates from the World Health Organization (WHO), the global under-five mortality rate has dropped by approximately 60% from 93 per 1000 live births in 1990 to 38 in 2021 (World Health Organization (WHO) 2023). Analysis of the kinds of child mortality cases reveals that neonatal deaths are the most common, even though mortality rates in children aged 0–28 days have gone down, the decrease is less than for the postnatal period. Worldwide introduction of pneumococcal vaccines since 2000 (including many LMICs) has had a significant impact on the prevention of this infection and led to a reduction in mortality caused by it. However, pneumonia is still one of the leading causes of mortality accounting for about one out of seven cases, mainly in LMICs (Liu et al. 2016). Diarrhea is also a major cause of mortality accounting for more than half a million deaths annually for children in LMICs (Tricarico et al. 2017).

Morbidity and mortality indicators are closely related to the children’s nutritional status. In LMICs, child malnutrition is still among major concerns. As an indicator of the “double burden“of nutrition, overweight and obesity are amongst the newly emerging problems. Globally, 149 m children under five are estimated to be stunted, 45 m are wasted and 39 m are overweight (BD 2017 Causes of Death Collaborators 2018). Among children aged 5–19 years, the burden of overweight is increasing and there are concerns regarding the effectiveness of interventions aiming to reduce the prevalence of obesity (Katoch 2022).

During the last decades, due to a sum of objective and subjective factors, there were significant increases overall in the prevalence of developmental disabilities, autism spectrum disorders (ASD), and attention deficit and hyperactivity disorders (ADHD) in children in both developed (Das et al. 2018) and developing countries (Zablotsky et al. 2019). In particular, data from the large-scale household survey conducted in Armenia with the support of UNICEF showed the prevalence of such conditions in children from 0 to 8 years old is as high as 11.6% (Olusanya et al. 2022). In line with developmental problems, other chronic conditions including asthma, obesity, and diabetes amongst others, are becoming increasingly common worldwide. Some epidemiological studies show that up to 1 in 4 children have a chronic disease with prevalence estimates ranging from 10% to 30% (Ministry of Health, National Statistical Service, Fund of Armenian Relief. UNICEF 2005). One in fifteen children has multiple chronic conditions, for instance obesity and/or asthma or diabetes (Compas et al. 2012).

Key factors related to children’s health outcomes include social welfare status, education census and care-seeking practices of the children’s families. There are a number of studies and reviews emphasizing the role of home care practices, time of referrals, etc. (Perrin et al. 2007). Health behaviors of school-age children and adolescents play an important role not only in their health at this age but also determines their health status in later life. Unhealthy dietary habits, tobacco and drug use, mental health issues, and other problems originate in school-age and adolescence and often impact health status and quality of live for an entire lifetime (Herbert et al. 2012).

Thus, despite significant achievements, pediatric systems worldwide, and especially in LMICs, are still tackling “old” problems while being confronted with “new” issues. To meet these challenges, the quality of care in health facilities should be improved. The quality of home care, care-seeking practices, and health behavior of the population should be improved and adapted to the current needs. Digital technologies, already in use in many settings, are one of the tools that can be used to improve child and adolescent health. They have the potential to increase the effectiveness of healthcare delivery, lead to organizational changes, improve health information systems and the exchange of these data among stakeholders, support continuous medical education of staff through easing access to educational materials, and improve communication between care-providers and care-takers. By using digitalization, nations and communities may achieve significant inputs in promoting Universal Health Coverage in LMICs which is one of the Sustainable Developments Goals of the United Nations (United Nations Sustainable Development Goals 2023). This narrative review focuses on the digitalization in pediatrics in LMICs, including specific examples. What practices in digitalization have been adopted in recent years and which are on agenda now? The following sections provide a high-level summary by field.

2 Respiratory Diseases

As mentioned previously, pneumonias and respiratory failure caused by them are still amongst the main causes of mortality in young children. Thirty years ago, the WHO developed guidelines to improve the management of pneumonias that were incorporated into the guidelines on Integrated Management of Childhood Illnesses in the late 1990s. The guidelines recommended using criteria of fast breathing and chest indrawing for early detection of cases of respiratory pneumonia in children under five (World Health Organization 2014). Introduction of these tools in the practice of many outpatient and in-patient care facilities led to a significant improvement in child health indicators in LMICs (Integrated Management of Childhood 2017). However, the protocol based on recognition of these signs had limitations in both sensitivity and specificity and there was a need for more precise measurement of respiratory failure. A solution that greatly improved pediatric practices was a timely invention by the outstanding Japanese engineer Takuo Aoyagi, who discovered a simple method of measuring oxygen saturation in arterial blood. Documents based on the WHO guideline including the “Pocket book of hospital care for children” (Pocket Book of Hospital Care for Children 2013) and “Pocket book for primary health care” (Pocket Book of Primary Health Care for Children and Adolescents 2022) both recommend using pulsoxymetry in children suspected of having pneumonia, and giving them oxygen if SpO2 is <90%. It provides health workers at first-level health facilities with easy-to-use tools, and help them to stratify the risk; however, pulse oximetry data should be analyzed in association with other danger signs. To expand usage of such pulsoxymetres in LMICs a balance needs to be found between the cost and quality of devices, as there is a concern that the pulsoxymetres available in LMICs are not always qualified (Exploratory meeting to review 2018). However, use of pulsoxymetres has been proven to be a very cost-effective intervention, costing 0.07 USD per patient which is especially important in LMICS (McCollum et al. 2019). The vital role of pulsoxymetry became highly evident during the COVID-19 pandemic. As an example, the “COVID Oximetry @home” program in the UK aimed to remotely monitor oxygen saturation in patients who were at risk of deterioration (United Kingdom 2023). Monitoring of patients’ oxygen enabled the identification of an early sign of deterioration and helped to triage patients with COVID-19 remotely and guided care escalation (Alboksmaty et al. 2022).

3 Neonatal Care

A systematic review has shown that digitalization has a good potential to improve perinatal and neonatal care. It is targeted to improving the quality of health-care both during delivery and after. There are positive results of introducing interoperable health information systems and electronic health records. Using digital technologies leads to improved diagnosis, better training of neonatal staff, promoting adherence to interventions in parents, and improving the overall quality of care (Duran et al. 2020). In particular, one study of applying telehealth in the evaluation of acute-phase retinopathy of prematurity has shown its high sensitivity and specificity (Quinn et al. 2014). Utilization of telehealth in the Neonatal Intensive Care Unit (NICU) led to increased support to families during their infant’s time in the hospital, decreased stress and anxiety of parents, and allowed them to bond and connect with their infant through remote baby viewing as well as build good relationships with the health staff (Ranu et al. 2021). Using mHealth technologies also improved communication between parents and neonatal staff and quality of home care of premature infants (Tenfelde et al. 2023).

4 Child Development

It was suggested that children with developmental disabilities may benefit from using a select kind of internet-based games. A systematic review showed that there are promising results regarding anxiety reduction, stress regulation, emotion recognition, and rehabilitation (Kokol et al. 2020). In particular, physical and occupational therapists have been using the low-cost gaming system for patients with developmental delays (Salem et al. 2012). There are studies which show that virtual reality as a proprioception method is a promising, cost-effective tool in the treatment of children with cerebral palsy (Monge et al. 2014). However, researchers believe that there is a need for more studies to find the best options to support the children with developmental problems and chronic health conditions.

It is well known that relevant behavior of the patient can support the management of chronic health conditions. The use of digital interventions may be a more cost-effective and accessible tool to guide patients. The most promising interventions targeted overweight or obesity through exergaming or social media, using web-based cognitive behavioral therapy, and typically using behavior change techniques such as feedback, monitoring, etc. (Brigden et al. 2020) There are also targeted studies assessing the effects of technology-based interventions on overweight and obesity treatment in children and adolescents. The results of reviews show that functional and acceptable technology-based approaches, in addition to “common” treatment, may enhance weight loss in young populations (Kouvari et al. 2022). Wireless Body Area Networks (WBANs) that focus on controlling obesity and overweight have been developed and have shown to produce promising results (Mohammed et al. 2018).

5 Health Care Organization and Delivery

One of the key directions of using digital technologies in healthcare are video clinical visits. The practice of virtual visits increased significantly during the COVID-19 pandemics. The analysis showed that such practices continued after the pandemics and expanded the capacities of health systems in many healthcare units worldwide (Mohammed et al. 2021).

The use of telemedicine in pediatrics has also increased in recent years. One systematic review analyzed studies where the quality of care and care-takers satisfaction was compared with in-person visits. The range of conditions included obesity, asthma, type-1 diabetes, and otitis media among others. The telemedicine interventions in all included studies resulted in outcomes that were comparable to or even better than the outcomes of control groups. These outcomes were related to symptom management, quality of life, satisfaction, medication adherence, visit completion rates, and disease progression (Shah et al. 2021).

During telemedicine visits, practicality of the real-time video Pediatric Gait, Arms, Legs, and Spine (v-pGALS) assessment have been used in the evaluation. The study showed that pGALS performed during telemedicine visits was a reliable tool to assess the musculoskeletal system in children (Kenis-Coskun et al. 2022). In another case, telemedicine consultations were provided to patients from rural areas that had difficulties to access specialized services. The results of this study showed that this practice led to an improvement in the quality of management of some dermatological conditions (Byrom et al. 2016). The cost-effectiveness of therapist-guided, internet-delivered cognitive behavioral therapy for children and adolescents with obsessive-compulsive disorder has been evaluated. The results show that for young people with obsessive-compulsive disorder, a low-cost digital intervention followed by in-person treatment for non-responders was cost-effective compared with in-person cognitive behavior therapy alone (Aspvall et al. 2021). Overall, it is evident that telemedicine services complement traditional, in-person health care resulting in a greater impact and improved quality of care. However, to maximize the potential of telemedicine, further research is needed to improve its regulations and mechanisms.

6 School Health

One of the fields of pediatrics bordering on public health is school health. School health is a mixture of various practices including school nursing, different programs, health educational activities etc. School health is a particularly good option to reach adolescents and provide care for them. Models for the provision of care in school health using opportunities provided by telemedicine have been described (North and Dooley 2020). In addition, innovative digital health interventions have been used for assessment, identifying the children who are at risk of developing psychological symptoms and providing support for those most at risk of mental health or related problems. The results showed that both teachers and schoolchildren found digital intervention usable and acceptable (Davies et al. 2021). However, there have been many barriers and further research is needed.

7 Health Education

There are many studies that show that child health status is directly related to parental health literacy. Worldwide, young people and young parents in particular, obtain health information from the Internet. The outcomes of digital health interventions on health literacy among parents of children aged 0–12 years have been assessed based on a systematic review of nearly 1500 studies, (Mörelius et al. 2021). The range of studies included evaluation of parents’ engagement, the effect of interventions on parental knowledge and health behavior, and the subsequent impact on child health outcomes. The review stressed the potential of digital health interventions to improve parental knowledge and behavior.

8 Continuous Medical Education

Digital education has the potential to deliver medical education to a large audience while limiting the number of trainers required. Researchers evaluated how effective digital education can replace traditional learning to improve continuous professional education of pediatric staff, improve their knowledge, skills, attitudes, and satisfaction. Results of 20 studies showed that digital education for post-registration health professions’ education in pediatrics is at least as effective as traditional learning and more effective than no learning (Brusamento et al. 2019).

This brief analysis, while presenting as complete an overview as possible, is subject to the limitations that are inherent in such an approach. Specifically, the narrative review provides a general overview of the field(s) without going into detail on any particular aspect. The latter would require a systematic review approach. Additionally, although the subject has often been mentioned in the international literature, few implementation examples have been published. This limits the available pool of published manuscripts that can be used throughout. Having said that, digital health in pediatrics is a relatively new field and it is developing rapidly. Therefore, this manuscript provides an overview of a field in its early stages and should be re-visited in the future in a more systematic way.

9 Conclusions

What are the conclusions of our brief analysis? Digital health applications will affect every aspect of pediatric healthcare provision and research, however, the speed at which this will be achieved will be highly dependent on the implementation context. Pediatricians, family doctors and nurses, health managers worldwide, especially in LMICs, meet many “old” and “new” challenges every day. In many LMIC settings, digital technologies may help them to reach better results. However, further studies are needed to find the optimal ways for using these technologies.