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Epidemiologia e Serviços de Saúde

versão impressa ISSN 1679-4974versão On-line ISSN 2337-9622

Epidemiol. Serv. Saúde v.26 n.1 Brasília jan./mar. 2017 


Hospitalizations of Brazilian children under fiver years old: a systematic review

Dixis Figueroa Pedraza1  , Erika Morganna Neves de Araujo2 

1Universidade Estadual da Paraíba, Programa de Pós-Graduação em Saúde Pública, Campina Grande-PB, Brasil

2Universidade Estadual da Paraíba, Mestranda do Programa de Pós-Graduação em Saúde Pública, Campina Grande-PB, Brasil



to describe the causes of hospitalization of Brazilian children under five years old.


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.


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.


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


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 hospitalization7. This list was built based on the 10th 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.


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 Health Sciences Information - Bireme). The search was held on January, 11th 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.


The flowchart which presents the process of identification and selection of the studies can be found in Figure 1. Eleven articles were included,1,2,3,11,12,17-22, four of them ecological2,12,17,22, 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.

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 

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 scope17,18, four of them focused on the Southeastern region, 1,3,19,21, three of them refer to the Southern11,12,20 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.

Table 1 - Distribution of the included studies in the systematic review concerning the causes for general hospitalizations ambulatory care sensitive conditions related hospitalization of Brazilian children under five years old, published from 2008 to 2015 

a) ICD-10: International Statistical Classification of Diseases and Related Health Problems - Tenth Revision

b) ACSC-related hospitalization: hospitalizations for Ambulatory Care Sensitive Conditions

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 groups1,21 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 list7 and the definition of the ICD-108 were used in one study.2 Regarding the hospitalizations under analysis, three studies12,17,22 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 under5, 2,3,18,20 respiratory diseases,2,11,18-20 diseases of the perinatal/neonatal period2,20 and surgical causes3,19 as causes of the most frequent hospitalizations (Table 2).

Table 2 - Main causes for hospitalizations of Brazilian children under five years old, according to the articles included in the systematic review and published from 2008 to 2015a 

a) Ferreira et al., 2014,1 did not define the causes.

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 asthma3,12,17,21,22 and infections of skin and subcutaneous tissue3,21 as the causes of hospitalizations cited more frequently. Three studies of them1,17,21 discriminated the results for children under one year old, reporting pneumonia,1,17,21 asthma,17,21 gastroenteritis1,17 and kidney infections and urinary tract1,21 as leading causes for admissions (Table 3).

Table 3 - Main causes for Ambulatory Care Sensitive Conditions-related hospitalization of Brazilian children under five years old, according to the articles included in the systematic review and published from 2008 to 2015 

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.

Figure 2 - Main causes for general hospitalizations and Ambulatory Care Sensitive Conditions-related hospitalization of Brazilian children under five years old, acoording to the included articles in the systematic review and published from 2008 to 2015 (n=11) 


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 problem, with more than half of Brazilian children affected, mostly in the Northeastern region of the country36,37, and in places with deficient conditions of sanitation and health education.38 This profile is also observed through the results of this research, since parasitic infections occupied a prominent position amongst the general admissions, and gastroenteritis amongst the ACSC-related hospitalizations.

It is worth to reaffirm that the PHC uses technologies of low complexity and high effectiveness, such as oral rehydration therapy and oral vaccine against human rotavirus, which are able to prevent gastroenteritis and its complications.34,35 Therefore, the indicated situation should be analyzed by considering the context of the structure and access of health units, as well as the predominance of the medical model of assistance in the daily life of health services through specific practices and healing actions, actions that go against the prospect of health promotion and prevention.23,25-27 In addition to the use of antiparasitic for the treatment of the parasitosis/enteritis in PHC, sanitation and environmental education measures are necessary, and reflects on the determinants of these conditions.6,18,39

The inclusion of asthma in the framework of the leading causes for children’s admissions, according to the results of this study, is reflected in the national statistics of the disease as a cause of large number of hospitalizations, especially of children in the age group up to the 6 years old (77.1 thousand hospitalizations in 2011), besides, it is of utmost importance to remember that asthma is responsible for the deaths of 2.5 thousand people each year.40 This reality may be conditioned by children’s health care, as shown in a study that highlighted the impact of simple practices in ambulatory care on asthma.41 It is pointed out that the management of this disease is carried out, for the most part, by punctual actions and approaches restricted to the symptomatic treatment of exacerbations, without early identification of the signs and symptoms that are essential in the prevention and resolution of the grievance.32 In the context of national policies, it is important that the professionals know and inform the citizen about the availability of free medications for asthma through the Popular Pharmacy Program.40

Kidney infections and urinary tract also represented important causes of admissions amongst children under one year old, according to the results. Children’s health care affected by these infections, through an early diagnosis, appropriate treatment and, in cases of recurrence, appropriate prophylaxis, can encourage the reduction of hospitalization and adverse effects resulting from the disease, such as pyelonephritis, with less likely therapeutic treatment in the ambulatory level.6 Concerning these infections and diagnosis, it is necessary to emphasize the importance of urinalysis, considered routine for its simplicity, low cost and ease of obtaining the sample; as for treatment, the use of drugs with antibiotics; and in case of recurrence, prolonged prophylaxis with antiseptic drugs.6,42 In children under one year old, breastfeeding may reduce the risk of urinary infections ambulatory care sensitive.42,43

In the context of general admissions, the perinatal causes revealed their relevance. The implementation of clinical protocol for the management of the prenatal care in PHC stands out amongst the priority measures to address adverse perinatal outcomes. It is suggested the impact of the following actions during the prenatal: supplementation with folic acid, vitamin A and iron; tetanus immunization; conducting examinations and treatment of infectious diseases; early diagnosis and treatment of hypertension and gestational diabetes; and calcium supplementation to prevent preeclampsia. Other relevant actions are increasing the amount of time between pregnancies and the presence of companion during labour.

It is appropriate to remember that the genesis of main diseases identified in this study as leading causes of ACSC-related hospitalizations is related to multiple circumstances to consider.12,17 One of them are the factors related to demographic and health profile of the population, to the network of health services available and to the specific context of the PHC/FHS (composition, qualification of human resources, employment bond, process of work and developed actions).12,17,44 Hence, FHS must face some challenges not only related to its structure and process of work, the due quality of PHC depends on the capacity to overcome some issues from these areas, but also the development of intersectoral actions in the confrontation of issues related to the social determinants of health-disease process.25

The results of this research should be analyzed with caution. First, the geographical concentration of the studies in the Southeast region limits the analysis of socio-spatial inequalities that characterize Brazil, and makes it impossible to extrapolate the results to the other regions or the whole country. The Southeast region is the largest one, and the concentration of production of scientific studies on it concerning ACSC-related hospitalization was also demonstrated in another review study,14 signaling the importance of developing greater amount of work in less developed regions of the country.

The methodological constraint imposed by the use of secondary sources in the Brazilian studies here organized matches the reality of the scientific production worldwide.45 In spite of the recognized inaccuracies resulting from secondary data and the possibility of fraud by financial issues, the national literature points out, too, that the hospital information system of the Brazilian National Health System (SUS) is characterized by its broadness and capacity to analyse the admissions in Brazil.12,14,46 Furthermore, important advances have occurred in the country in recent decades, in the process of implementation of health information systems, with the expansion of coverage, access to and use of national databases.47

Other limitations of this review can derive from the use of different lists of admissions by the different researches, and the consequent restraint for comparison of the results. In addition to this, there is not a specific descriptor about the ACSC-related hospitalization, which makes more complex the bibliographic search about the topic. The critical evaluation of the ecological studies, through an instrument that is not specific to this type of delineation, should also be mentioned. Nevertheless, it is important to emphasize that there is no similar proposal to those studies, studies included in this review resemble the cross design ones, for its characteristics of temporality, calculations of ACSC-related hospitalization rates and definition of the causes of admissions.

Despite the aforementioned limitations, the findings of this study represent a warning signal in order to trigger mechanisms for analysis and search for explanations for the occurrence of admissions, especially those related to the ambulatory care sensitive conditions (ASCS). The presented results allow an overview of the causes of hospitalizations, the general ones and the ambulatory care sensitive conditions in Brazilian children younger than five years old.

We concluded that pneumonia, gastroenteritis and asthma still are important causes of hospitalization amongst children, albeit they are preventable and treatable with the use of lower cost technologies currently available. When analyzed the hospitalizations in general, the reality is similar. In addition to the perinatal diseases, respiratory diseases and parasitic infections stand out, these two include, respectively, pneumonia and gastroenteritis. This is a worrisome panorama, considering the existence of the Family Health Strategy for more than two decades. The understanding of the importance of health promotion and disease prevention, as a practice directed toward children under the age of five, is essential to minimize the complications and hospitalization derived from morbidity in this segment of the population.


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Received: June 15, 2016; Accepted: July 29, 2016

Correspondence: Dixis Figueroa Pedraza - Av. das Baraúnas, No. 351, Bairro Universitário, Campina Grande-PB, Brasil. CEP: 58429-500. E-mail:

Figueroa Pedraza D and Ahmad EMN participated in the design of the study, survey, data analysis and interpretation, writing and critical review of the manuscript. Both authors have approved the final version of the manuscript and declare to be responsible for all aspects of the work, ensuring their accuracy and integrity.

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