The parents 'educational conditions are one of the factors of health inequalities among children. During May 2009, the parents' instruction level of children admitted at the triage unit of a Pediatric Service in Antananarivo, Madagascar was evaluated and related to the severity of their children' health status and to the mode of reference. All the surviving children (from 2 months to 15 years old) were included in this study. Patients were classified by the IMCI guideline and we analyzed the educational level of their mothers. Each patient was classified as severe illness or without severe illness, according to IMCI algorithm. The quality of referring physician was recorded: public physicians, liberal physicians, nurses, or without referral. Among 296 children, 9 (3%) died before admission, 217 (75.6%) were included. Among them, 123 (56.7%) had a severe illness and 38,2% general signs of danger. The severity (92.3 versus 54.4%; P = 0.003), the number of severe dehydration (15.4 versus 3.9%; P = 0,027) and malnutrition (15.4 versus 4.4%; P = 0.039) were related with a poor parents educational level. The referral agents were mostly liberal physicians (56.7%), public physicians (26.7%) or nurses (1.8%). Mothers with higher educational level preferred to attend liberal physicians (58 versus 41.9%; P = 0.1). The reference delay was shorter if there was a severe illness (6.41 versus 19.6 days; P < 0.000) or no medical referral (51.1 versus 24.4%; P > 0.000). Despite the fact that access to hospital care was respectful of a two-step process (85.3%), the number of patients with severe illness was high among families with low educational level. Theses results suggest to educate in priority the mother with low education, in order to recognize the general signs of danger and facilitate early first health care.

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Since its recommendation by WHO, Oral Rehydration Solutions (ORS) contributed in reducing the rate of mortality due to acute gastroenteritis. In Madagascar, the rate of lethality imputed to gastroenteritis is about 3%. Rehydration can be performed either by using spoons which reliability is unsure because of parents' potential inobservance and child's refusal, or by nasogastric tube. The nasogastric tube may resolve these obstacles at the hospital. We realized a preliminary study to evaluate the efficacy and the safety of nasogastric tube and spoon administration of the ORS in rehydration of child with moderate post-gastroenteritis dehydration. This is an open comparative study realized in the Pediatric Unit at the Joseph-Raseta-Befelatanana Hospital from the 21 January to 21 May 2008. Main outcomes was the proportion of rehydrated children at 4 hours, other were: failure at 8 hours, duration and volume of SRO, side effects. Fifty-three children from 4-month to 4-year old among 1306 patients were recruited and forty-seven patients were included. Nine patients failed (4 children received ORS by spoon and 5 children by nasogastric tube). The use of spoon was more effective: 62.5% of the patients were rehydrated at the fourth hour versus 39.3% in nasogastric tube group (P = 0.04). Making debit constant presents difficulties in rehydration with nasogastric tube (44.4 %). Tolerance of nasogastric tube is generally good but 16.7% children get out their tube during this study. No ORS' inhalation was observed with both routes. No false passage or tube or ORS rejection was recorded in both techniques. This study shows that using spoon to rehydrate is more effective for the rehydration of moderate dehydration. The use of nasogastric tube needs more surveillance.

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