NEW YORK (Reuters Health) – Children in low- and middle-income countries (LMICs) are more likely than those in high-income countries to die from the most common gastrointestinal congenital anomalies, according to a large prospective study.
“Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries,” researchers with the Global PaedSurg Research Collaboration write in The Lancet.
“Conditions associated with a normal lifespan for most individuals in high-income countries are frequently fatal within days of life for neonates born with the same conditions in LMICs,” they report. “This study provides evidence that Sustainable Development Goal 3.2 to end preventable deaths in neonates and children younger than 5 years by 2030 is unachievable without urgent action to improve neonatal surgical care in LMICs.”
Dr. Naomi J. Wright of King’s College London and colleagues searched standard databases for observational or randomized studies published in English over twenty years. They collected data on the clinical status, interventions, outcomes and demographics of 3,849 patients under 16 years of age who were hospitalized for any of the seven most common gastrointestinal congenital anomalies from 264 hospitals in 74 countries: 89 in high-income countries, 166 in middle-income countries, and nine in low-income countries.
Across all income groups, median gestational age at birth and median bodyweight at presentation were similar, at 38 weeks and 2.8 kg, respectively.
The researchers analyzed data from patients hospitalized for anorectal malformation, congenital diaphragmatic hernia, esophageal atresia, exomphalos, gastroschisis, intestinal atresia, or Hirschsprung’s disease.
The children received primary surgical intervention, conservative treatment, or palliative care, and were categorized as alive if they were discharged alive or remained in the hospital 30 days after the start of care or 30 days after admission if they did not receive an intervention.
The researchers recorded surgical-site infection, wound dehiscence and need for unplanned reintervention within 30 days of surgery as well as mortality within 30 days of the first intervention.
In low-income countries, 37 of 93 (40%) children died; in middle-income countries, 583 of 2,860 (20%) died and in high-income countries, 50 of 896 (6%) died (P<0.0001 between all income groups).
Newborns with gastroschisis had the greatest mortality disparity related to country income, with a rate of 90% in low-income countries versus 32% in middle-income and just 1% in high-income countries (P<0.0001 between all income groups).
For all patients combined, country income was significantly linked with higher mortality (low vs. high: risk ratio, 2.78; middle vs. high: risk ratio, 2.11). Other significant factors included sepsis at presentation, higher American Society of Anesthesiologists (ASA) score at primary intervention, surgical safety checklist not used, and ventilation or parenteral nutrition unavailable when needed.
“The results of this study highlight the urgency for increased attention to paediatric surgery in global health, and can be used to advocate for the dedication of resources to paediatric surgical care and neonatal critical care in LMICs. Collaboration between providers in high-income countries and LMICs, and prioritisation of LMIC leadership, will be essential to these efforts,” Drs. Sarah C. Stokes and Diana L. Farmer of the University of California, Davis, Medical Center, in Sacramento, write in a linked commentary.
“Over the past few years, the Global Initiative for Children’s Surgery has worked to advance global paediatric surgery through the development of standards for paediatric surgical care at each level of a health-care facility, and with the Global Assessment of Pediatric Surgery tool,” they add. “Further research into specific infrastructure and resource needs of paediatric surgical care centres in LMICs is urgently needed, as is training of paediatric surgeons and anaesthetists.”
SOURCES: https://bit.ly/37xYj6i and https://bit.ly/3yHSrDu The Lancet, online July 13, 2021.
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