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EDITORIAL Table of Contents   
Year : 2008  |  Volume : 5  |  Issue : 1  |  Page : 1-2
Perspectives on congenital abnormalities in the third world


Department of Paediatric Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa

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How to cite this article:
Hadley G P. Perspectives on congenital abnormalities in the third world. Afr J Paediatr Surg 2008;5:1-2

How to cite this URL:
Hadley G P. Perspectives on congenital abnormalities in the third world. Afr J Paediatr Surg [serial online] 2008 [cited 2014 Jul 25];5:1-2. Available from: http://www.afrjpaedsurg.org/text.asp?2008/5/1/1/41626
Congenital abnormalities happen, and when they do they create stress in the parents, medical staff, and of course the patient.

In the Third World, affected neonates are often further disadvantaged with regard to intrauterine nutrition, transplacental infections including HIV, prematurity, poor obstetric care, and late diagnosis. In many sub-Saharan African countries, the expertise for management of readily correctable abnormalities is lacking, further adding to the rate of attrition. Additionally basic facilities, taken for granted in the First World, such as post-operative ventilation, total parenteral nutrition (TPN), chromosomal studies, or blood component therapy, are simply unavailable. Unsurprisingly, the mortality rate for a variety of abnormalities is high.[1],[2]

The successful management of a neonate with a significant congenital abnormality does not depend on the availability of surgical skills alone, but reflects the effectiveness of the entire healthcare chain from antenatal care, through obstetric care, the diagnostic acumen of the primary healthcare provider, investigational infrastructure, transportation facilities and care, pre- and post-operative nursing expertise in addition to the intraoperative teamwork between the surgeon, anaesthetist, and theatre personnel. Deprived of these support structures, the most diligent surgeon would be totally ineffective.

It is of course vital that paediatric surgeons, or general surgeons who perforce, have children as a proportion of their constituency, maintain their skills at diagnosis and the initial surgical treatment of common abnormalities. All surgeons in practise in Africa should be confident in the performance of neonatal colostomy or herniotomy for example, and they need to be taught such procedures. But the results will not improve unless we recognize that neonatal surgical care is a team event and we start to involve the entire team in developing and maintaining their expertise.[3]

As any chain is only as strong as its weakest link, particular attention should be paid to the primary care level for, without prompt diagnosis and intelligent primary intervention, all later interventions become redundant.

Similarly, neonatal transport requires a high order of skill, organization, and preparedness. Improvements in these areas will yield greater results than merely sharpening the needlepoint of surgical expertise.[3],[4] Where facilities are inadequate, efforts must be made to upgrade them for no purpose is served by transporting a baby badly as it is the general condition of the patient on arrival at the treatment center that largely determines the outcome.[3] Primary care and ambulance staff must be made to understand that their role is pivotal, and to take pride in their achievements, and this is best effected by positive feedback.

It is also appropriate for surgeons in Africa to seek novel approaches that are relevant to the patients we serve rather than slavishly follow dicta from our colleagues in resource-rich regions; dicta that generally depend upon a level of technological sophistication unimaginable in the Third World. We need to reconsider the non-operative management of anterior abdominal wall defects and develop affordable techniques for closing gastroschisis; we need to relook at distal feeding enterostomies in babies with small bowel atresias to avoid the need for TPN; we should be reassessing the role of temporizing maneuvers in Hirschprung's disease and anorectal malformations, hypospadias, and a variety of other lesions. Should the definitive operation be performed on an older child making peri-operative care easier and safer? We need to look scientifically at novel anesthetic approaches, such as neonatal caudo-thoracic epidurals, to avoid the need for post-operative ventilation following repair of esophageal atresia[5] and other major thoracic or upper abdominal procedures.[6] We also need to evaluate the capabilities of our general surgical colleagues and assist them in defining referral criteria as well as offering training in the specifics of paediatric surgical care. There is much to do.

Certainly our patients are entitled to the best care that we can offer and if what we can offer is limited by the resources at our disposal, then we must ensure that those resources are used in a way that maximizes the child's quality of life without consuming resources that are needed to support other children. In Africa, that means minimizing our dependence on sophisticated technology and maximizing the skill base that already exists in our institutions.

 
   References Top

1.Iliff PJ. Neonatal surgery in Harare Hospital. Centr Afr J Med 1990;36:11-5.  Back to cited text no. 1    
2.Borgstein ES. Gastroschisis minor. J Ped Surg 2001;36:1504-5.  Back to cited text no. 2    
3.Pazvakavambwa IE. An experience with surgical admissions to a paediatric ICU in Harare, Zimbabwe. Central Afr J Med 2004;50:107-10.  Back to cited text no. 3    
4.Hadley GP, Mars M. Improving neonatal transport in the Third World-Technology or teaching? S Afr J Surg 2001;39:122-4.  Back to cited text no. 4    
5.B φsenberg AT, Hadley GP, Wiersma R. Oesophageal atresia: Caudo-thoracic epidural anaesthesia reduces the need for postoperative ventilatory support. Pediatr Surg Int 1992:7;289-91.  Back to cited text no. 5    
6.Hodgson E, B φsenberg AT, Hadley GP. Congenital diaphragmatic hernia: Impact of delayed surgery and epidural analgesia. S Afr J Surg 2000;38:31-5.  Back to cited text no. 6    

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Correspondence Address:
G P Hadley
Department of Paediatric Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban
South Africa
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DOI: 10.4103/0189-6725.41626

PMID: 19858653

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