title: Delayed diagnosis of anorectal malformations (ARM): causes and consequences in a resource-constrained environment.
abstract: OBJECTIVE
  Delay in diagnosis or referral of patients with an anorectal malformation (ARM) is associated with significant morbidity and mortality. We describe the frequency and consequences of delay in recognition or referral of patients with ARM. Our study aims to determine whether the source healthcare facility affects the timing of diagnosis and to identify modifiable factors that may expedite diagnosis and referral.
  
  
  METHODS
  Retrospective study of patients referred to a pediatric surgical service with a newly diagnosed ARM between July 2002 and December 2010. Data retrieved included patient demographics, perinatal history, time of diagnosis, clinical findings, management, and morbidity and mortality. Delay was defined as diagnosis after 24 h of birth or transfer to the tertiary referral centre more than 24 h after diagnosis.
  
  
  RESULTS
  273 patients (186 males, 87 females) were referred during the study period. Delays were seen in 158 (57.9%) patients with morbidity in 58 (36.7%, p < 0.001) and mortality in 9 (5.7%, p = 0.008). Delay was more frequent amongst babies born in community health centres (CHCs) than in hospitals (90.5 vs. 55.1%, p = 0.002). The median age at diagnosis was 3 days (range 2 days to 5 years).
  
  
  CONCLUSIONS
  There is a need for staff education, particularly in CHCs, concerning routine neonatal examination and normal perineal anatomy. Girls, in whom a decompressive fistula is often present, are at particular risk of diagnostic delay. Delay causes increased morbidity and mortality.
authors.affiliation: Department of Pediatric Surgery, Inkosi Albert Luthuli Central Hospital, Durban, South Africa. saveshgov@gmail.com.|School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa. saveshgov@gmail.com.
authors.forename: S
authors.initials: S
authors.lastname: Govender
authors.affiliation: Department of Pediatric Surgery, Inkosi Albert Luthuli Central Hospital, Durban, South Africa.|School of Clinical Medicine, College of Health Sciences, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
authors.forename: R
authors.initials: R
authors.lastname: Wiersma
mesh_terms: D000071056:Anorectal Malformations / Q000150:complications / Q000175:diagnosis* / Q000453:epidemiology*; D002675:Child, Preschool; D057210:Delayed Diagnosis; D005260:Female; D006268:Health Facilities / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D008297:Male; D009017:Morbidity; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D012307:Risk Factors; D013019:South Africa / Q000453:epidemiology; D013997:Time Factors
keywords: Anorectal malformation; Delay; Morbidity; Mortality