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Perspectives on perioperative management of children’s surgical conditions during the COVID-19 pandemic in low-income and middle-income countries: a global survey
  1. Paul Truche1,2,
  2. Alexis Bowder1,2,
  3. Amber Trujillo Lalla3,
  4. Robert Crum2,
  5. Fabio Botelho4,
  6. Henry Elliot Rice5,
  7. Bellisa Caldas Lopes6,
  8. Sarah Greenberg7,8,
  9. Faye Evans9,
  10. John Gerard Meara1,10,
  11. Emmanuel Adoyi Ameh11 and
  12. David Patrick Mooney2
  1. 1Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts, USA
  2. 2Department of Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
  3. 3University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
  4. 4Hospital das Clinicas da Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
  5. 5Division of Pediatric General Surgery, Duke Children's Hospital and Health Center, Durham, North Carolina, USA
  6. 6Department of Pediatric Surgery, Instituto de Medicina Integral Prof. Fernando Figueira, Recife, Brazil
  7. 7Department of Surgery, University of Washington, Seattle, Washington, USA
  8. 8Division of Pediatric General & Thoracic Surgery, Seattle Children’s Hospital, Seattle, Washington, USA
  9. 9Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
  10. 10Department of Plastic and Oral Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
  11. 11Division of Paediatric Surgery, Department of Surgery, National Hospital, Abuja, Nigeria
  1. Correspondence to Dr Paul Truche; paul.truche{at}


Background Many organizations have issued recommendations to limit elective surgery during the coronavirus disease 2019 (COVID-19) pandemic. We surveyed providers of children’s surgical care working in low-income and middle-income countries (LMICs) to understand their perspectives on surgical management in the wake of the COVID-19 pandemic and how they were subsequently modifying their surgical care practices.

Methods A survey of children’s surgery providers in LMICs was performed. Respondents reported how their perioperative practice had changed in response to COVID-19. They were also presented with 26 specific procedures and asked which of these procedures they were allowed to perform and which they felt they should be allowed to perform. Changes in surgical practice reported by respondents were analyzed thematically.

Results A total of 132 responses were obtained from 120 unique institutions across 30 LMICs. 117/120 institutions (97.5%) had issued formal guidance on delaying or limiting elective children’s surgical procedures. Facilities in LICs were less likely to have issued guidance on elective surgery compared with middle-income facilities (82% in LICs vs 99% in lower middle-income countries and 100% in upper middle-income countries, p=0.036). Although 122 (97%) providers believed cases should be limited during a global pandemic, there was no procedure where more than 61% of providers agreed cases should be delayed or canceled.

Conclusions There is little consensus on which procedures should be limited or delayed among LMIC providers. Expansion of testing capacity and local, context-specific guidelines may be a better strategy than international consensus, given the disparities in availability of preoperative testing and the lack of consensus towards which procedures should be delayed.

  • child health
  • health services research
  • pediatrics

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • Twitter @ptruchemd, @abowder, @AmberTLalla, @mendesbotelho, @bellisacaldas, @SLMGreenberg, @DrFayeMazoEvans, @johnmeara, @eaameh

  • Contributors All authors contributed to study conception and design, including review of survey content and questions. TPR performed data acquisition. TPR, LAT and BA performed data analysis. All authors contributed to writing and critical revisions of the paper and all authors approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests The Program in Global Surgery and Social Change reports financial support from the Klejtian Foundation, Ronda Stryker and William Johnson, and from the General Electric Foundation.

  • Patient consent for publication Not required.

  • Ethics approval Institutional review board exemption (IRB P00035176) was obtained through Boston Children’s Hospital (April 1, 2020).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement The data that support the findings of this study are available on request from the corresponding author, TPR. A full copy of the survey instrument is available in the appendix.

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