Academic journal article Bulletin of the World Health Organization

Surgical Services for Children in Developing Countries. (Public Health Reviews)

Academic journal article Bulletin of the World Health Organization

Surgical Services for Children in Developing Countries. (Public Health Reviews)

Article excerpt

Introduction

Perhaps the most significant advance associated with the surgical care of children during the past century has been the realization that "children are not small adults". Rather, children develop distinct surgical conditions, present unique anaesthetic challenges, and have special perioperative needs. Moreover, the consequences of paediatric surgical conditions may be lifelong since they affect children at critical times during development.

The recognition that the surgical needs of children differ from those of adults has led to remarkable improvements in care. Many children with congenital anomalies that were once thought incompatible with life are now living normally. Severely injured children are restored to normal function, failed organs are replaced, neonatal surgery has become routine, and the efficacy of fetal surgery is being investigated in clinical trials.

Nevertheless, there are still major gaps in the surgical care of children living in developing countries. Paediatric surgery has often been viewed as too expensive and as a nonessential service, and it has been excluded from most child health programmes in such countries.

The inadequate surgical care of children in developing countries has not been without consequences. In many of these countries, congenital anomalies go unrepaired, treatable injuries result in lifelong disabilities, and children die of easily correctable surgical problems, e.g. airway foreign bodies and incarcerated inguinal hernias.

Burden of childhood surgical diseases

The most important issue surrounding the surgical care of children in developing countries is the burden of surgical diseases (a) on paediatric populations. Epidemiological data on this subject are scarce.

The pattern of paediatric surgical diseases in sub-Saharan Africa (b) provides an insight into this. We focus on sub-Saharan Africa both because it has the greatest disparities in health care (c) and is the one with which we are most familiar (2). Patterns of disease and the availability of resources vary between regions of the world, but sub-Saharan Africa epitomizes many of the challenges inherent in attempting to provide surgical care for children in developing countries.

The available information suggests that surgery patients are responsible for approximately 6-12% of all paediatric admissions in sub-Saharan Africa, although the proportion may be higher in some urban areas. At the main government referral hospital in Banjul, the Gambia, surgical patients accounted for 11.3% of paediatric admissions (3). The commonest admission diagnoses were injuries, congenital anomalies, and surgical infections, accounting for almost 90% of paediatric surgical admissions (Fig. 1). At the rural Ahmadu Bello University Teaching Hospital, Malumfashi, northern Nigeria, paediatric surgery represented 6.6% of the paediatric workload and 9.6% of all operative procedures (4). The most frequent operations performed in this hospital were for congenital problems (40%), infections (22%), and traumas (21%).

Injuries

Injuries are the commonest surgical problem affecting African children. For children in Africa who survive the first four years of life, injury becomes the most likely cause of disability and death, a situation that remains true until the fourth decade of life (5). In a recent review of injuries and noncommunicable diseases in developing countries, childhood disability-adjusted life years (DALYs) related to injuries were the highest in sub-Saharan Africa (6) DALYs related to injuries were higher among males than females and among children aged 0-4 years than among those aged 5-14 years.

That injuries are a significant cause of death and disability among African children should not be surprising, since, in most established market economies, they are the leading cause of death and disability for the age group 1-19 years. …

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