Abstract Invasive traditional practices which are frequently harmful are common in the care of children including neonates in developing countries. We report two cases of evisceration of intra-abdominal viscera in two neonates subjected to abdominal scarification with razor blades following febrile illnesses. The greater omentum and a loop of jejunum, respectively, were eviscerated. Both were successfully managed and discharged home. Consent was obtained from the parents for the use of the photos. These cases highlight the dangers of invasive traditional practices on neonates and the urgent need for enlightenment campaigns as well as enactment of policies to help protect these children in developing countries. evisceration, abdominal scarification, neonates, traditional INTRODUCTION Harmful invasive traditional practices are common in the care of children including neonates in developing countries . Abdominal markings or scarification, one of such, involves making multiple markings with sharp instruments such as razor blades, knives and broken bottles on the abdomen. This is done with the aim of removing presumed ‘bad blood’ accumulation in a child with febrile illness and/or abdominal swelling . Two cases are reported here of neonates subjected to abdominal scarifications with razor blades following febrile illnesses, resulting in evisceration of the greater omentum and a loop of jejunum, respectively. They both had exploratory laparotomies including repair of abdominal wall injuries and were discharged home in good clinical condition. CASES Case 1 A 2-week-old female presented at the children’s emergency room with a 10 h history of ‘protrusion of intestine’ from the abdomen following abdominal markings with razor blade by a native doctor. The neonate was noticed to be febrile on the third day of life and persisted despite administration of native herbal medications. There was no history of abdominal swelling or seizures. The child was thereafter taken to a native doctor. Examination revealed an acutely ill-looking neonate, febrile, pale and dehydrated. She had tachycardia. There was a dusky-looking extruded intra-abdominal viscus at the peri-umbilical region, as well as multiple incisions measuring about 0.5–1 cm each, on the anterior abdominal wall and back (Fig. 1). Fig. 1. View largeDownload slide A 2-week-old with multiple scarification injuries and eviscerated omentum. Fig. 1. View largeDownload slide A 2-week-old with multiple scarification injuries and eviscerated omentum. Her white blood cell count and hemoglobin concentration were 17 000/mm3 and 8.5 g/dl, respectively. Serum electrolytes were normal. She was adequately resuscitated and had an emergency exploratory laparotomy. Findings were eviscerated edematous greater omentum extruded through an incision measuring about 1 cm, without any other intra-abdominal injury or gross intra-abdominal pathology. The eviscerated omentum was excised and she was placed on intravenous Cefuroxime and Metronidazole post-operatively. She did well and was discharged on the ninth post-operative day. No complication was noted afterward. Case 2 A 3-week-old female presented with a 4 h history of ‘protrusion of intestine’ from the anterior abdominal wall, following abdominal scarification with razor blade by a native doctor. The child was noticed to be febrile on the 12th day of life. There was no history of abdominal distension or swelling. After administration of several over-the-counter drugs, she was taken to a native doctor who attributed the child’s symptoms to ‘Ude’ and carried out the procedure. Examination revealed an acutely ill-looking child who was febrile. There was an eviscerated edematous loop of small bowel protruding from the right hypochondrium, with multiple skin incisions measuring about 0.5–1 cm each over the entire abdomen (Fig. 2). Fig. 2. View largeDownload slide A 3-week-old with scarification injuries and eviscerated small bowel loop. Fig. 2. View largeDownload slide A 3-week-old with scarification injuries and eviscerated small bowel loop. Her white blood cell count was 13 000/mm3. Hemoglobin and serum electrolyte concentrations were normal. She was adequately resuscitated and had emergency exploratory laparotomy. Findings were eviscerated viable loop of jejunum through one of the markings measuring about 1.5 cm, without other intra-abdominal viscera injury or gross intra-abdominal pathology. The abdominal wound was closed and the patient was placed on intravenous Cefuroxime and Metronidazole. She was discharged on the seventh post-operative day. No complication was noted afterward. DISCUSSION The two cases managed within a span of 2 years showed that abdominal scarification for various ailments is still a common practice in this sub-region. Abdominal scarification is a traditional medical practice that entails use of sharp instruments such as razor blades, broken bottles and knives to make multiple markings on the anterior abdominal wall . It has been a common practice with varied indications among Edo people, a major ethnic group consisting of numerous clans spread across Southern Nigeria. The commonest indication from community surveys is abdominal swelling perceived to be splenic enlargement called ‘Ude’ by the Edo people [3–6]. Other indications include fever, seizures and ‘evil spirit affliction’ [4, 5]. Furthermore, among the Edo people, even in the absence of abdominal swelling, any child with complaints of abdominal pain or perceived discomfort is ‘diagnosed’ as having ‘Ude’ and is routinely given the abdominal scarification treatment. Osifo et al.  in 2007, in a retrospective study of 22 patients aged between 6 days and 12 years who presented with abdominal swelling at the University of Benin Teaching Hospital, found that all cases were attributed to ‘Ude’ and had abdominal scarification as treatment. This procedure is usually done by a native doctor who is believed to be ‘specialized’ in the treatment of such ailments . It is believed that the ‘bad blood’ flows out through the wounds created . Concoction, sometimes consisting of ash or herbs, is applied over the wounds [2, 3]. Unfortunately, these native doctors are often the first point of call of most parents with ill children, even among well-educated ones . For most Africans, childhood illnesses have a spiritual connotation. This explains why the homes of these native doctors have become the primary health care centers in most African countries as well as India [8, 9]. Sadly, abdominal scarification is one of the many harmful traditional practices that are common place in newborn and infant care. These include facial markings, branding, cow dung application on the umbilical cord, uvulectomy and tattooing [1, 3, 4, 7–9]. There are several reports of complications in children subjected to abdominal scarification. In the study by Osifo et al. , all 22 children studied developed complications, with >90% being life threatening, including severe dehydration, anemia and respiratory failure; a scenario similar to what occurred in these two cases reported. Tsiba et al.  in Congo reported local infection, sepsis and pulmonary-pleurostaphylococci complicating scarifications in children studied. Furthermore, this practice accounts for delay in hospital presentation resulting in high morbidity and mortality from easily treatable conditions. Patients with abdominal tumors often present in advanced stages in addition to sepsis and anemia . The complication spectrum appears to have expanded with the index cases of evisceration, as there are sparse previous reports in the literature. Additionally, the cases highlight the use of significant force during this procedure, as razor blades were used in both. Over the years in Nigeria, attempts have been made to stop this practice including the 2003 Child Rights Act and awareness campaigns by non-government organizations. Cases however remain rampant [2, 11]. CONCLUSION/RECOMMENDATION Abdominal scarification remains a mainstay in the treatment of childhood illness among traditional medical practitioners and is associated with life-threatening complications. Increased health awareness campaigns, enactment and enforcement of laws prohibiting this practice are advocated. References 1 Peterside O , Duru C , Anene N. Harmful traditional practices in a newborn: a case report . Niger J Paed 2015 ; 42 : 151 – 3 . 2 Abdominal Scarification (Belly markings- ′Ude′) . Adoghe's online public health clinic. www.aophc.com/abdominal-scarification.html (28 January 2017, date last accessed). 3 Osifo O , Evbuomwan I , Efobi C. Management of childhood abdominal masses by Nigerian traditional doctors: a worrisome cause of delay in presentation . Pak J Med Sci 2007 ; 23 : 809 . 4 Adeleye O , PF I. Parents' attitude to abdominal scarification as therapy for splenic enlargement in children: a community-based study in Southern Nigeria . Ajms 2011 ; 3 : 134 – 8 . 5 Ibadin O , Ofili A , Airauhi L , et al. Splenic enlargement and abdominal scarification in childhood malaria. Beliefs, practices and their possible roles in management in Benin City, Nigeria . Niger Postgrad Med J 2008 ; 15 : 229 – 33 . Google Scholar PubMed 6 Wagbatsoma V , Aimuengheuwa O , Agabi J. Assessment of abdominal scarification as a treatment for malaria-induced splenomegaly in a rural community: implications for child health . Vulnerable Child Youth Stud 2007 ; 2 : 106 – 15 . Google Scholar CrossRef Search ADS 7 Kiran B , Kumar SR , Vyshak A , et al. Infected wound on the chest and abdomen following branding mark in an infant-a harmful practice . Ijhimr 2014 ; 1 : 46 – 7 . 8 Sadik E , Gobena T,BM. Aspects of common traditional medical practices applied for under five children in ethiopia . J Community Med Health Educ 2013 ; 3 : 237 . 9 Kumar S , Rashmi S. Branding: a harmful practice . Indian Pediatr 2005 ; 42 : 721 . Google Scholar PubMed 10 Tsiba J , Mabiala-Babela J , Lenga L , et al. Scarification in children hospitalized in Congo . Med Trop 2011 ; 71 : 509 – 10 . 11 Nigeria: The practice of tribal markings on male children, including groups that engage in the practice; whether the parents of a child can refuse to have the practice carried out, including consequences of such a refusal; state protection available. 2013 . http://www.refworld.org/docid/546dc28a4.html (29 April 2017, date last accessed). © The Author . Published by Oxford University Press. All rights reserved. For Permissions, please email: firstname.lastname@example.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)
Journal of Tropical Pediatrics – Oxford University Press
Published: Jun 10, 2017
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