People who have experienced pyloric stenosis (“PS”), either in their early infancy or as the parents of a very sick baby, will probably realize that such babies would most likely have starved to death if they had been born more than a century ago. During the first 30 years after the publication of an effective surgical treatment for PS (Ramstedt’s pyloromyotomy) in 1912, the death rate fell from close to 100% to below 5% in most wealthy countries, and today it is well below 1% in those countries.
But that is still not true everywhere. Do we ever stop to think what it’s like to have a PS baby today in an underdeveloped and poor country?
In the week before Christmas this subject will get some attention in this post. I have found 3 medical reports from Africa on which to base this piece, but sadly and to me inexplicably, these articles are only available to the general public in “Abstract” form: read “a very brief summary”. Most of us cannot afford US$40 per article to read such material, and surely these 3 reports are not “of rolled-gold value” to the medical world; they were written well over 20 years ago and relate to data even older and from very needy countries far from the domains of most of our readers. Besides, they aim to improve what may be rather basic pediatric skills and treatment.
Grrrr! In fact I feel anger and disgust at the medical publishers who (according to recent news reports) maintain this choke hold on medical information… in the interests of medical science? Shareholders? Raw opportunism? Who knows?
The 3 Abstract reports relate to PS cases in Ghana between 1974 and 1988, in five years before 1991 in Dar-es-Salaam in Tanzania, and in Addis Ababa (Ethiopia) between 1981 and 1986. Click on the links to read them in their complete Abstract form.
Here are some of the things I found interesting…
- The 15 year Ghanaian study of 84 infants saw 9 boys having surgery for every girl, far more than the usual incidence ratio which has been found to range between 2.6:1 and 5:1.
The 5 year review from Dar-es-Salaam saw only 15 PS babies, with a male: female ratio of 6.5:1, also higher than among Caucasian (white) populations. The PS incidence rate was (as is well known) much lower among Tanzanian Africans: about 1:5,500 live births.
The report from Ethiopia related to 34 babies seen over 6 years, and saw an incidence rate approaching Caucasian levels: between 2.7 and 3.6:1,000. The male:female ratio was 4.7:1, also much closer to the Caucasian ratio.
- It is also well-known that first-born babies have a higher risk of developing PS. Almost 24% of the Ghanaian babies and 26.5% of the infants seen in Addis Ababa were first-born. The Abstract of the report from Dar-es-Saalam did not mention this statistic.
- The Ghanaian article reported a 3.6% mortality rate: 6 of the 84 infants. Two of the 15 babies followed in the Tanzanian study died after their Fredet-Ramstedt pyloromyotomy, a relatively high mortality rate of 6.7% (but on a very small number). In the Ethiopian report, none of the 40 patients died after surgery but 7 developed complications.
- The report from Ghana mentioned that 10.7% of the 84 babies followed had other congenital abnormalities, which is consistent with studies elsewhere and a much higher figure than among the general population. The Abstract did not mention which other abnormalities were found but other reports often mention intestinal malrotation, defects of the urinary tract, and esophageal atresia; inguinal (groin) hernias also occur often in infants after PS but these are probably collateral damage from the strains of PS rather than genetically, biochemically or otherwise developmentally linked.
- The report from Ghana stated that fully 1/3rd of cases started vomiting in their first week after birth. “The peak-age of presentation and diagnosis was between the second and sixth weeks of life.”
The Tanzanian article’s Abstract did not include this subject.
The report for Addis Ababa stated that 76% of babies started vomiting during their first month, and that all babies started to show symptoms during their first 3 months with an average age of 3 weeks.
- The Ethiopian report included several other findings that are quite typical of PS:
– 23.5% of the babies were from the higher socio-economic groups (well above average);
– no seasonal variations were found (contradicting several other reports);
– a “pyloric olive” (a tumour that could be felt) was detected in 35% of babies.
Although my comments can only be based on three very succinct Abstracts of much more detailed reports, several things are significant to me.
Developing countries 20 or more years ago were struggling to catch up with the wealthier countries, reflected here in their surgical treatment of PS. Having followed the flow of generally available medical reports on PS related issues from all over the world since 1997, it is clear to me that while many “centres of excellence” have emerged in the developing world during this time, there are also many signs that little has changed in many poor countries, under-resourced hospitals and the skills of surgeons trained and working in them.
- It is probably true the these three Reports reflect that the more recent progress in many of the planet’s poorer countries mirrors in a delayed way the progress that took place in Europe and North America in the earlier decades of the 20th century.
- None of these three Abstracts mentions treating PS medically as the safer, cheaper and less technology- and skills-demanding alternative to surgery, a recommendation that I have read recently for contexts such as the African one. One wonders whether self-interest or good management drives this obvious preference for surgery that is usually unnecessary and certainly more traumatic for parents and baby.
- Comparing these three reports reminds me of
(1) the many standard features, variations and mysteries that remain around PS, and
(2) something of what PS surgery was like when I was born in 1945.
There has been progress world-wide! When I was born almost 70 years ago, most PS babies outside the developed world would have died.
But even in the 1980s this was no longer true! What will the next 70 years bring?