Hazel M. Gutiérrez, MD – Head Pediatric Palliative Care and Pain Control Unit, National Children’s Hospital “Dr. Carlos Sáenz Herrera”
Dr. Gutiérrez is a pediatric palliative care specialist, professor at the University of Costa Rica and a pediatric bioethicist. Her work focuses on improving PPC education and guiding healthcare workers through the daily ethical dilemmas they face when caring for children with life-threatening and life-limiting conditions.
Featured Article
Downing, J., Brand, T., Daniels, A., El-Khoury, J., Gafer, N., Palat, G., Riga, O., Szylit, R., & Garcia-Quintero, X. (2025). Reducing inequity in the provision of children’s palliative care in low- and middle- income countries: A focus on education and research. Palliative Medicine, 02692163251348091.
Commentary
Inequity in children’s palliative care provisions in limited-resource countries “Over 98% of the nearly 21 million children worldwide who could benefit from palliative care live in low and middle-income countries (LMICs), yet the majority of these settings lack pediatric palliative care (PPC) services, trained personnel or consistent access to essential medicines.”1-4 This in itself, is an overwhelming paradox.
The editorial from Downing et al. (2025) addresses the persistent inequities in the provision of children’s palliative care in LMICs. The authors remind us that inequity in children’s palliative care is not merely a technical gap, but a reflection of broader social injustice. The article argues that reducing inequity requires more than expanding services; it demands intentional and equity-focused strategies that address structural, socioeconomic, and geographic barriers. The editorial highlights two priorities for reducing PPC inequity in resource-limited settings: strengthening education and training, and expanding locally generated research. The authors emphasize the importance of providing accessible PPC training models, empowering children’s palliative local leaders, developing equitable collaborations and mentorship to learn from each other. Also, there is a call for the “decolonization” of children’s palliative care and research through rebalancing power dynamics, intentionally hosting international conferences in LMICs with relevant content for all settings, establishing initiatives to reduce financial barriers, promoting equitable participation, and supporting local researchers, particularly when writing in other languages.
Blatman et al. (2025) interviews humanitarian healthcare professionals about their perspectives on children’s palliative care, and preferences and needs for training. A key finding from the study was the preference for virtual training on theoretical topics, and hands-on training for palliative care skills, particularly communication. The study also describes important health system barriers to training and implementing PPC that we also have in Latin America: inadequate physical space within health facilities, a limited number of trained staff, and limited availability of opioids and other essential medicines.
In México, Ramos-Guerrero et al. (2025) analyzes the development of PPC using an adaptation of the World Health Organization’s assessment model. The authors identify significant regulatory advances; however, they underscore a persistent gap between regulation and effective implementation, largely attributed to the fragmentation of the health system and the absence of a current national plan with allocated funding. Although there has been a progressive increase in pediatric palliative care teams, these remain insufficient and are concentrated mainly in highly specialized hospitals, with limited home and perinatal coverage. Also, the authors detail a barrier that many PPC physicians working in LMICs could relate with, access to essential medicines, particularly opioids, represents one of the main challenges due to low consumption, supply problems, a shortage of pediatric formulations, and prescription restrictions.
Houston, et al (2023) analyzes 112 institutions across 23 countries caring for children with cancer from low (LIC), lower-middle (LMIC), upper-middle (UMIC), and high (HIC) income levels. Their findings show that access to specialists varied by income level with 71% of HICs, 41% of UMICs, 32% of LMICs, and 17% of LICs reporting almost always having access to palliative care specialists. When it comes to the availability of oral morphine, it was reported to be always available in 100% of HICs, 76% of UMICs, 27% of LMICs, and 33% of LICs and injectable morphine in 100% of HICs, 96% of UMICs, 41% of LMICs, and 33% of LICs. Personally, I find these results heartbreaking to read. The author’s conclusion is a painful reality: “Access to pediatric palliative care services varies by income level. Despite increased need for palliative services in LMICs, there is less access to trained providers and essential medications, especially in those with decreased resources.”7
Downing et al. (2025) frames equity in children’s palliative care as a moral imperative – one that requires humility, shared responsibility, and global collaboration to ensure that no child is left to suffer without care. So, how do we reduce the inequity in children’s palliative provision in limited-resource countries?
For the past 16 years, I’ve worked as a PPC physician in Costa Rica, a LMIC with a privileged social healthcare system compared to other countries in Central America. When I met a dear colleague from a neighboring LIC, and we discussed our own barriers and limitations for providing quality care in our PPC programs, I realized I shouldn’t complain, but rather be grateful. This meeting emphasized the realities of this inequity, and my perspective instantly changed forever.
Ultimately, all healthcare professionals who care for children and young people with life-threatening or life-limiting illnesses, regardless of the country they live in, should reflect on this question. We must encourage ourselves to actively participate in the answer, because outside our own reality or comfort zone, there will always be a colleague with fewer resources than us, who is required to adequately care for their patients and their families.
References
- Houston, L. C., McNeil, M., Le, M. A., Forrest, H., Gonzalez-Guzman, M., & Friedrich, P. (2023). A global assessment of access to pediatric palliative care for children with cancer in resource-constrained settings. JCO Oncology Practice, 19(11 Supplement), 87.
- Connor SR, Downing J and Marston J. Estimating the global need for palliative care for children: a cross-sectional analysis. J Pain Symptom Manage 2017; 53(2): 171–177.
- Knaul FM, Farmer PE, Krakauer EL, et al. Alleviating the access abyss in palliative care and pain relief: an imperative of universal health coverage: The Lancet Commission report. Lancet 2018; 391(10128): 1391–1454.
- World Health Organization. Integrating palliative care and symptom relief into pediatrics: A WHO guide for health care planners, implementers, and managers. Geneva: World Health Organization, 2018.
- Downing J, Chambers L, Daniels A, et al. Mapping of children’s palliative care development globally in 2023. Children 2025; 12(4): 440.
- Ramos-Guerrero, J. A., Barrientos-Deloya, A., Correa-Morales, J. E., Dorsey-Rivera, B. E., Ismail-Paz, E. F. E., Guadarrama-Orozco, J. H., & Zuniga-Villanueva, G. (2025). Development of pediatric palliative care in Mexico: Adapted review of the World Health Organization model. Revista Mexicana de Anestesiologia, 48(1), 46EP – 54.
- Blatman, Z., Rayala, S., Richardson, K., Risat, M. I. K., Yantzi, R., & Doherty, M. (2025). Children’s palliative care perceptions and educational needs among healthcare professionals in humanitarian settings. Palliative & Supportive Care, 23, e4
TRENDS 2025; Special Edition 2: Low Resource Settings
Click the links below to view this months full list in desired format.
Abath, K. M., Levy, S. S. S., & Duarte, M. D. C. M. B. (2025). Practice of pediatric palliative extubation in Brazil: A case series. Crit. Care Sci., 37.
Ajambo, M., Rujumba, J., Mwaka, S., Nyanzi, J. G., Nalwanga, D., & Balagadde, J. (2025). Paediatric Palliative Care following Hospital discharge: Prevalence and factors associated with non-continuity of palliative care for children with cancer in Busoga sub-region-eastern Uganda; A mixed methods study. medRxiv, 2025.01.07.25320167.
Al Majed, B. (2025). Parental autonomy and children’s health: A patriarchal dilemma in the Middle East, with particular emphasis on Kuwait. Medical Law Review, 33(1).
Aldas, S., Ersoy, M., Durukan Tosun, M., Ozgokce Ozmen, B., Tunc, A., & Sahin, S. (2025). Assessment of Caregiver Burden and Burnout in Pediatric Palliative Care: A Path Toward Improving Children’s Well-Being. Healthcare (Basel, Switzerland), 13(13).
Alvarado García, A. M., Vargas-Escobar, L. M., Arias-Rojas, M., Avendaño-Vásquez, C. J., & Consuegra-Pareja, C. A. (2025). Anxiety, depression, and quality of life of caregivers of palliative care patients with cancer. Revista Cuidarte, 16(1), 1–13.
Blatman, Z., Rayala, S., Richardson, K., Risat, M. I. K., Yantzi, R., & Doherty, M. (2025). Children’s palliative care perceptions and educational needs among healthcare professionals in humanitarian settings. Palliative & Supportive Care, 23, e42.
Coleman, C. C. (2025). Death Is Too High a Price to Pay for Being Born an Impoverished and Ill Child. American Journal of Bioethics, 25(2), 145–148.
Downing, J., Brand, T., Daniels, A., El-Khoury, J., Gafer, N., Palat, G., Riga, O., Szylit, R., & Garcia-Quintero, X. (2025). Reducing inequity in the provision of children’s palliative care in low- and middle- income countries: A focus on education and research. Palliative Medicine, 02692163251348091.
Houston, L. C., McNeil, M., Le, M. A., Forrest, H., Gonzalez-Guzman, M., & Friedrich, P. (2023). A global assessment of access to pediatric palliative care for children with cancer in resource-constrained settings. JCO Oncology Practice, 19(11 Supplement), 87.
Iqbal, R., Siddiqui, A., Khan, W., Pasha, A., Aziz, D. A., & Rahman, A. (2025). Short-term outcomes of treatment limitation discussions in neonatal care units of tertiary care hospital in Karachi, Pakistan: A cross-sectional study. BMJ Paediatrics Open, 9(1).
Jain, S., Agrawal, A., Sharma, S., & Chinnadurai, R. (2025). Impact of nutritional status on the outcome of critically ill pediatric patients. World Journal of Clinical Pediatrics, 14(2), 103377.
Jordan, S., Nilmanat, K., Duffus, Y., & Campbell, C. (n.d.). Palliative care interventions used by village health volunteers in Thailand. International Journal of Palliative Nursing.
Keerthana, S. B., & Kubendran, A. (2025). Pediatric palliative care in low-income and middle-income countries: A systematic review on current status and future directions. Médecine Palliative.
Laabar, T. D., Norman, R., Saunders, C., Alam, M. U., & Li, I. W. (2025). Using discrete choice experiments to elicit palliative care preferences in lower middle-income countries: An exploratory study in Bhutan. Palliative Care & Social Practice, 4(25).
Laabar, T. D., Rayala, S., Lynch-Godrei, A., Bhandari, P., & Doherty, M. (2025). The impact of a children’s palliative care education and mentoring program (Project ECHO) on healthcare providers’ knowledge, confidence, and attitudes in Bhutan. Palliative & Supportive Care, 23, e89.
Li, L., & Gong, X. (2024). Development of Patient-Centered End-of-Life Care Quality Measures in China: A Modified Delphi Process. Journal of Palliative Care, 8258597241302297.
Mascarenhas, D., Goyal, M., Raghavendra, P. R., Raman, R., Talawadekar, P., Muckaden, M. A., Deodhar, J., Nanavati, R., & Haribalakrishna, A. (2025). Establishing a Neonatal Palliative Care Program in a Tertiary Level Neonatal Intensive Care Unit. Indian Journal of Pediatrics.
Mathe, T., Mitrea, N., Ancuta, C., Cormack, C., & Rogozea, L. (2025). Communication Preferences in Pediatric Palliative Care: Insights From Caregivers and Specialists-A Central-Eastern European Perspective. Journal of Hospice and Palliative Nursing : JHPN : The Official Journal of the Hospice and Palliative Nurses Association.
Mauree, A., Myezo, K., Ranasinghe, N., Challinor, J., Bandini, R., Burns, K., Eyal, K., Downing, J., Pritchard-Jones, K., Bouffet, E., & Geel, J. (2025). African Hospital-Based Paediatric Palliative Oncology Care Independent of Economic Indicators: An International Society of Paediatric Oncology (SIOP) Global Mapping Programme Survey. Pediatric Blood & Cancer, 72(5), e31598.
Maurya, B. P., Gupta, R., Rathore, P., Mishra, S., Bharati, S. J., Kumar, V., Gupta, N., Garg, R., & Bhatnagar, S. (2025). End of Life Care Practices at a Tertiary Cancer Centre in India: An Observational Study. American Journal of Hospice & Palliative Medicine, 42(5), 477–482.
Nath, A., Mathur, P., Sudarshan, K. L., Arora, R., Seth, R., Kumar, S., Chinnaswamy, G., Budukh, A., Singh, V., Kumari, T. P., Banipal, R. P. S., Bodal, V. K., Kumar, A. R. A., Vijay, C. R., Avinash, T., Ramesh, C., Gundeti, S., Malik, S., Chaudhary, N. K., … Bhutia, T. W. (2025). Stakeholder’s Perspectives on the Barriers and Facilitators of Childhood Cancer Care in India. Indian Pediatrics, 100235.
Nehls, N., Börner, M., Ziegelmayer, S., Haller, B., Klot, F. F., Metzler, M., Frühwald, M. C., Schlegel, P., Corbacioglu, S., Feuchtinger, T., & Lüttichau, I. T. (2025). Raising Awareness: Real World Data On Palliative Care for Advanced Pediatric Cancers in Bavaria. Pediatric Blood & Cancer, 72, 9.
Oztek Celebi, F. Z., Bozdag, Y., Boybeyi, S. D., Oguz, M. M., Altinel Acoglu, E., Senel, S., & Sahin, S. (2025). Validation of the Turkish adaptation of FACETS-OF-PPC: a multidimensional outcome measure for pediatric palliative care. Frontiers in Oncology, 15, 1510099.
Peck, J. L., Flippo, R., Sudia, T., Rosonet, L. E., Maganthi, M., Siew, A., Johnson, S. R., & Garner, S. L. (n.d.). Neonatal and paediatric palliative care interdisciplinary education in India. International Journal of Palliative Nursing.
Raj, T. A. S., Harrison, J., Wakefield, C. E., Daur, B., Felmingham, B., Casey, M., McLoone, J. K., Sullivan, M., Staffieri, S. E., & Anga, G. (2025). Building capacity to treat childhood cancer in Papua New Guinea: “It’s a multidisciplinary village.” Journal of Global Health, 15, 03008.
Ramos-Guerrero, J. A., Barrientos-Deloya, A., Correa-Morales, J. E., Dorsey-Rivera, B. E., Ismail-Paz, E. F. E., Guadarrama-Orozco, J. H., & Zuniga-Villanueva, G. (2025). Development of pediatric palliative care in Mexico: Adapted review of the World Health Organization model. Revista Mexicana de Anestesiologia, 48(1), 46EP – 54.
Rassam, R. S., Lion, R. R., Cherkaoui, S., Hessissen, L., Garcia-Quintero, X., Najjar, L. S., Noun, D., Hanna, J., Yamout, R., Resham, S., Habaiba, K. A., Al-Nassan, A., El-Khoury, J., Rayala, S., Alotaibi, Q., Gafer, N., Troisi, G., Downing, J., Rasul, S., … McNeil, M. J. (2025). The first regional interdisciplinary paediatric palliative care (PPC) workshop for the Eastern Mediterranean Region: A groundbreaking collective step for PPC integration. Ecancermedicalscience, 19, 1948.
Rent, S., Titchiner, D., Rholl, E., Lyle, A., Diego, E., North, K., Rahiem, S., Garmon, A., Gaffur, R., Shayo, A., Diez Recinos, A. L., Lemmon, M., & Docherty, S. L. (2024). Perinatal palliative care in low- and middle-income countries: A scoping review. Annals of Palliative Medicine, 13(6), 1420–1448.
Resham, S., Altaf, S., Ayub, F., Bhatti, A., Syed, A., Iqbal, R., Tul Quanita, A., Vitória Ramos de Oliveira, C., Fadoo, Z., Mushtaq, N., Imam, U., Raza, M. R., & Yousafzai, A. K. (2025). Exploring Pediatric Oncology Care Practices Influencing the Relationships Among Children, Caregivers, and Health Care Providers: A Multi-Institutional Study From Pakistan. JCO Global Oncology, 11(11), e2400347.
Rihani, R., Awidi, A., Barbar, M., Mustafa, M., Tutunji, L., Rayyan, Y., Mansour, A., Abdel-Razeq, H., & Sultan, I. (2025). Advancing paediatric cancer care in Jordan: A strategic 10-year roadmap. The Lancet Child and Adolescent Health, 9(7), 497EP – 507.
Shevchuk, O. M., Shevchuk, A. M., Holovash, O. O., Mykhailenko, O. O., & Ivanytsia, A. O. (2025). Protection of children’s rights to access palliative medical services: Legal problems. Wiadomosci Lekarskie (Warsaw, Poland : 1960), 78(6), 1078–1082.
Spolador, G. M., Polastrini, R. T. V., Zoboli, I., Henrique, A. C., Freitas, E., do Nascimento, A. G., Monti, F., Pugliese, C., Kok, F., Barbosa, S. M. M., & Bueno, C. (2025). Adaptation of Pediatric Palliative Care Groups to Metabolic Diseases: Beyond the Pathways. Annals of Pediatrics.
Stevenson, G., Namukwaya, S., Katongole, J., Tumukunde, V., Blencowe, H., Seeley, J., Tann, C. J., Lawn, J. E., Elbourne, D., & Medvedev, M. M. (2025). “I have to be strong”: A qualitative study of parental bereavement experiences in Uganda following the death of their baby. Women & Birth, 38(2), N.PAG-N.PAG.
Tukisi, K. P., van Rensburg, Z. J., & Jacobs, W. (2025). Midwifery manager’s experiences of knowledge and skills utilization by midwife specialists in the public health sector of South Africa. BMC Nursing, 24(1), 1–9.
Zhou, N., Ren, F., Shi, G., & Wang, J. (1387). Understanding the Relationship Between Peer Support and Grief/Growth in Chinese Shidu Parents: The Roles of Internalized Stigma and Stigma Resistance. Omega: Journal of Death & Dying, 91, 3.iterature for pediatric chronic pain. The Journal of Pain.