Childhood Surgical Conditions

 

                Childhood Surgical Conditions

Circumcision

Circumcision refers to the  cutting of the fore skin of the penis. Therefore skin or prepuce covers the glans or the soft front portion of penis.

Circumcision may be done :

• For religious reasons
• For any complication
• For no definite reason

The foreskin is normally  adhered to the glans penis in most newborns. If nothing is done it separates on its own by the age of three or so in almost all the cases. Therefore instruct people at home  not to make any attempt to retract the fore skin. If it is still adhered, you may yourself try to gently push the foreskin behind and clean any stuff between the skin and glans penis.

If no separation of the fore skin is noticed by the age of 4 years  consult a pediatric surgeon.

Do not circumcise because the child has a long foreskin or is wetting the bed or has ballooning of the foreskin while passing urine, but has no other problem. Some reports indicate that  circumcision  reduces the overall incidence of urinary tract infections. Circumcision should be  considered if a child with an adhered prepuce gets repeated attacks of urinary infection in absence of any proven obstruction in the urinary tract.

 People who believe circumcision should be done as a routine minor operation do not realize that  even this operation can cause infections, excessive bleeding and other problems. if religious reasons dictate circumcision, get it done by a doctor. Defer the operation to a later date if the baby was premature or had some complication at birth.

Do not circumcise in case of Hypospadias

Pediatrician surgeons warn against circumcision in hypospadias, a condition in which  the opening of the urinary passage  is on the under surface of the penis. In these male infants, the urethra  (urinary tube) is deficient  and the circumcision must be categorically avoided as the  excess foreskin on the penis is used  to construct the deficient urethra. The penis bears a nearly circumcised look after this operation.

Cleft Lip and Palate

Cleft of the lip with or without cleft of the palate is a common birth defect. With surgery, these defects can be closed with good cosmetic effects.

The cleft lip operated upon  when the baby is about 3 months of age. Surgery for the cleft palate is usually undertaken between the age of  1 and 2 years. Some operate cleft lip cleft lip and cleft palate simultaneously with good results at 11 months of age.

These babies can be breastfed, though their mothers may need extra support. Most babies with only cleft lip (without cleft palate)  have no difficulty in breastfeeding. The mother should offer enough of breast into the baby's mouth for the breast to close over the cleft so that he can suckle well. . The idea is to help mother use her areola (dark portion of the breast behind the nipple. to fill in the defect and form a seal.

Suckling is more difficult in the presence  of a cleft palate. The baby may seem to  choke sometimes or milk may leak through the nose.  The baby may choke less if the mother holds her baby in a more upright position while breastfeeding.. If the baby is not able to manage  direct suckling in one position, the mother should  try feeding in different position. One such position is called 'the modified football hold position'. In this position , the mother sit up on a bed , she makes the baby sit upright  opposite her breast, with his legs along her side  and his feet at her back. She holds the child's head  in her hand  to offer the breast and uses her other arm to support his back. A pillow kept under the baby's bottom  may be found to be helpful.

'The modified football hold position'.

Direct suckling may not work  with some babies. The milk  should than be expressed and given to the baby  in a cup or with a dropper (or by a tube) until the baby is able to suckle well enough  at the breast. It has been found that  irrespective of the mode of feeding, babies with cleft lip  tend to gain weight rather slowly.

After surgery for cleft lip, some surgeons allow direct  suckling from the breast  as soon as the baby leaves the recovery room. They believe that unlike bottle feeding , the soft breast does not damage the stitches.  In any case there is no need to stop direct  suckling for more than a few hours.  If direct sucking is delayed for any reason, the mother should keep expressing her milk every 3 hours.The milk can be given to the baby  with a cup or bondla (paladai) or a spoon.

Breastfeeding is now recommended even in a second year of a child's life. So after the child recovers  from surgery for cleft lip , direct breast feeding can be started again in a week or so.

Toeing-in and Cub Foot

If the feet of a child are turned inwards but have normal movement at the ankle  joints, they need no treatment. It may be due to a particular position of the  baby while he was in the mother's womb.  This condition returns to normal  by about 6 months of age. If the toeing-in persists or it appears rigid, the child may have a condition called 'club foot' (Congenital telipes equinovarus). This may need an orthopedic opinion. Such children need repeated plastering. Sometimes, surgery is also indicated.

Hypospadias

In this condition, the opening of the urinary passage is on the outer surface of the penis. Besides there is usually a downward bending or curvature of the penis. In severe degree of hypospadias, the opening of the urethra  may be at the junction of penis and scrotum or even further backwards on the scrotum or in front of anus. In such cases, the scrotum may be divided by a deep cleft into two parts (bifid scrotum). If, in addition one or both the testes are missing from the scrotum, the surgeon will have to determine the sex of the child  as it may be an 'intersex' condition.

Treatment

Hypospadias can be corrected surgically, either in a single surgery or in 2 stages, depending on the surgeon. An average hospital stay of 10 days is necessarily. The ideal age  for surgery is between 8 and 18 months.

Circumcision should  be categorically avoided in babies with hypospadias as the excess foreskin heaped on the penis  is used to construct the deficient urethra..

All the procedures should be completed before the child starts attending school.

Appendicitis

Appendicitis refers to inflammation of Appendix, a tail like structure  connected the caecum portion of large intestine located in the right lower abdomen. If not detected early, an inflamed appendix may burst open, leading to a serious condition called peritonitis. A child with a possible diagnosis of appendicitis needs immediate attention of a pediatric surgeon.

Intestinal Obstruction

Intestinal obstruction is a serious surgical condition. Some of the cases are congenital obstruction (from birth), a mass of round worm obstructing  the intestine, intussusception and an obstructed inguinal hernia.The child has pain in abdomen, constipation, distention of the abdomen and projectile vomiting (vomit shooting out of the mouth). It may be green in color (due to presence of bile) or may even contain feces.The urgent case of a surgeon is vital.

Intussusception

Intussusception is a condition in which  one portion of the intestine slips inside the portion next to it. The condition occurs commonly between the ages of 3 months and 3 years.

There is a sudden onset of pain which last for 2-3 minutes and then occurs in repeated bouts every quarter hour or so. While a child becomes red in the face when he cries, in intussusception, the child looks pale, acutely ill, refuses to eat or drink  and appears to be collapsing with continuing bouts. At this stage, the child may pass blood in the stool.

A surgical opinion is urgently needed  in such a situation. .

Inguinal hernia

Torsion of Testis
Umbilical Hernia

This is quite common. In most cases it does not need any treatment.
This hernia  becomes more prominent after the child cries. Crying results in increase intra-abdominal pressure. This pushes the abdominal tissue through the umbilicus because of a small gap in the abdominal muscles in that region.
The hernia should be left alone. You may be advised by others to put a coin on the swelling part and tie it up. This is not required. In fact, if the leucoplast is  used to keep the coin in lace for a number of days, your child may get an itchy rash on the skin.
The swelling generally disappears by the time the child enters his second year. In rare cases, surgery may be required.

Umbilical Granuloma

You may notice that, after the umbilical cord of new born has fallen off, a red moist swelling is left behind. This is the umbilical granuloma.
 The standard practice is to touch it with a silver nitrate stick to dry it. Or just put a crystal of rock salt (cleaned with boiled and cooled water and dried) on the swelling.  Keep it in place with leucoplast or a band - aid. The swelling disappears within a few days in most cases.If no improvement is noted by use of these methods, a minor surgery may have to be undertaken.
Undescended Testes

Soon after the birth of a male child, both the testes can be felt lying inside the scrotum. sometimes, the scrotum may appear 'empty'  on one side or both sides. The reason could be varied.
In the fetus, testes lie inside the abdomen. They come down just before the expected time of delivery. If the baby is born just before the expected time, it may take some time before we can feel the testes.
Some testes are called 'shy' testes or 'retractile' testes. These are normally present in the scrotum but soon as the scrotum is touched, especially with the cold hands, the testes tends to go up in the abdomen, making the scrotum appear empty. Such a testes does not need any treatment. This child will have a normally functioning testicles.
If one or both testes are really missing from the scrotum, we wait until the child is 1 year old. If after that, it cannot be felt on one or both side, it is advisable to see a surgeon, preferably a pediatric surgeon. If the surgeon is convinced that it is undescended testes surgery will be advised to bring it down and to fix it into the scrotum. Although some surgeons believe in postponing the surgery till the age of 2 or 3 years. But it is advisable to operate around 6 months, because electron microscope studies have revealed that the undescended testes may undergo degenerative changes after 6 months.
If both the testes are not felt, and the clinical examination  reveals some doubt, the doctor may ask for a test to determine the sex of a child.
There are two possible risks involved in leaving the testes inside the abdomen. The first is degeneration and infertility and the other is the development of cancer of the testes.
Here a passing reference is made about uneven testes in an adolescent. Assure your teenage that it is quite normal for one testes is lower than the other.
Children with undescended testes may have an associated hernia, which is seen as a swelling coming up  in the groin when ever the child cries or strains. In such cases, it is advisable to operate upon the undesended testes as early as possible, because hernia in a small infant tends to be obstructed.

Tracheoesophageal Fistula (TOF)

A Rare Condition Needing Attention

Mothers may suspect it first before the nurses or doctor  think of it. If a new born baby has excessive salivation or coughs or vomits each time you give a feed. Early diagnosis of this condition is important.

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