872 Anorectal malformations The incidence of anorectal malformation is 1/5000 live births. Anor ectal malformations comprise part of the VACTERL association (see b p.848). The abnormality should be identi \201 ed at birth. The baby presents with: \200 \200 \200 failure to pass meconium; abdominal distension; bile-stained vomiting. Anatomy The precise anatomy varies but the malformation can be subdivided into high and low /intermediate anomalies in males and females. Low/intermediate anomalies \200 \200 Rectum is present and passes through a normal sphincter complex. In boys (Fig. 23.17) there is a tiny \201 stulous track to the surface of the perineum, often anteriorly on to the scrotum. If meconium is visible on the perineum a local \200\230cut-back \200\231 procedur e can be performed to open the \201 stula back to the rectum in anticipation of normal co ntinence. In girls (Fig. 23.18) the rectum usually opens into the back of the introitus as a rectovestibular \201 stula. This abnormality is termed intermediate because, although n ormal continence is to be expected, reconstruction involves division of a common wall betwe en rectum and vagina. For this reason treatment involves a 3-stage procedure with defunctio ning colostomy, anorectal reconstruction, and then closure of the stoma. Vesicoureteric re \202 ux is very common. High anomalies \200 \200 These anomalies are rare in girls but common in boys (Fig. 23.17). The sphincter complex is poorly developed and the prospects for continence are mediocre. In boys the rectum makes a \201 stulous connection with the urethra. Treatment involves a defunctioning colostomy w ithin the \201 rst 48hr of birth, reconstruction at a few months of age (most commonly in volving a posterior sagittal anorectoplasty performed through a midline perineal incision), and then closure of the colostomy. 23_McClure_23.indd 872 11/14/2012 3:30:24 PM ANORECTAL MALFORMATIONS 873 Low anomaly \200\223perineal fistula High anomaly \200\223recto-urethral fistula Recto-urethral fistula lies above the levator ani which is deficient Rectum passes through the levator ani sphincter Recto-urethral fistula Site of anus Fistula from rectum onto perineum Site of anus Fig. 23.17 Male anorectal malformations. Intermediate anomaly \200\223recto-vestibular fistula Low anomaly \200\223perineal fistula Rectum passes through a normal levator ani complex Rectum passes through a normal levator ani complex Stenotic anterior perineal opening Site of anus Site of anus This anomaly is termed \200\230intermediate \200\231 because of the common wa ll between the rectum and the vagina, which makes reconstruction complex Rectum opens into posterior fourchette of the introitus Fig. 23.18 Female anorectal malformations. 23_McClure_23.indd 873 11/14/2012 3:30:24 PM CHAPTER 23 Pediatric surgery 874 Umbilical anomalies Granuloma The commonest umbilical abnormality seen in infants is an umb ilical granu- loma (see Fig. 23.19). This is a harmless reaction to the resolving umbilical stump and usually disappears by the 2nd to 3rd week. Treatment A persistent granuloma should be cauterized with a silver nitrate stick. Vaseline should be applied round the umbilicus to prevent damage to the surrounding skin and a smal l dressing placed over the umbilicus to prevent marking of the baby \200\231s vest. Multipl e applications may be necessary. (cid:1) Caution A persistent \200\230granuloma \200\231 discharging small bowel contents s igni \201 es a patent vitello-intestinal duct (Fig. 23.19). Treatment involves surgical ex ploration of the umbilicus and excision of the duct with a small segment of ileum. The diag nosis is clinical. Urachal remnants These are uncommon anomalies that present in infancy or early child- hood. The urachus is an embryonic tubular connection between the blad- der and the allantois tha t normally obliterates before birth. \200 \200 Main Bladder excluded by micturating cystography. Treatment is surgical closure. symptom: persistent discharge of urine from the umbilicus. outlet obstruction (posterior ur ethral valves) should be Umbilical hernias (Fig. 23.19) \200 \200 Common, particularly in Afro-Caribbean children. Most will close spontaneously during the \201 rst few years of life, regardless of size. Complications are rare. If the hernia fail s to close surgical repair can be performed at around 5yrs of age. \200 23_McClure_23.indd 874 11/14/2012 3:30:25 PM UMBILICAL ANOMALIES 875 Typical umbilical hernia (large, easily reducible protrusion into umbilical skin) Vitello-intestinal fistula visible as intestinal mucosa in the umbilical stump Cord clamp Umbilical granuloma Fig. 23.19 Disorders of the umbilicus. 23_McClure_23.indd 875 11/14/2012 3:30:25 PM CHAPTER 23 Pediatric surgery 876 Testicular torsion Testicular torsion must be excluded in a child with acute scrotal pain. The peak incidence occurs around 12yrs, but it can occur at any age. \200 Congenital has a hard, painless scrotal mass. Testis has invariably infarcted and explorati on is not necessary, nor is \201 xation of the opposite testis. The pathology is torsion of the spermatic cord outside the tunica vaginalis. Torsion outside the perinatal period: t he result of an abnormally mobile mesentery of the testis inside the tunica vaginalis. This anomaly is bilateral and allows the gonad to twist on its vascular pedicle. testicular torsion: rare perinatal event. Newborn infant Presentation \200 Sudden onset severe scrotal pain, often associated with nausea and vomiting. Tender testis. Overlying scrotal skin may be reddened and oedematous. \200 Treatment \200 Immediate scrotal exploration is mandatory to salvage the testis, which should then be \201 xed to prevent recurrence. The contralateral testis should also be \201 xed. Differential diagnosis of acute scrotal pain See also b p.877 Testicular torsion \200 \200 \200 Sudden onset pain, swelling, and nausea Testis is very tender, and may lie transversely in scrotum Scrotal skin may be red Torted hydatid \200 \200 \200 Gradual onset of less severe pain; no nausea Focal tenderness at upper pole of testis Torte d hydatid may be visible through scrotal skin as a pea-sized blue/black swelling Epididymo-orchitis \200 \200 \200 Insidious onset of dysuria and fever Usually associated with a urinary tract infection Red tender scrotum Testicular trauma History obvious and there are signs of trauma/ haematocele Idiopathic scrotal oedema \200 \200 \200 Child is well Scrotal skin is cellulitic but the testes are not tender The condition settle s spontaneously within a few days 23_McClure_23.indd 876 11/14/2012 3:30:25 PM ORCHITIS AND EPIDIDYMITIS 877 Orchitis and epididymitis Orchitis \200 Orchitis is an uncommon condition in boys that presents with fever and testicular pain. App roximately 20% of prepubertal patients with mumps develop orchitis (see b p.713). Diagnosis based on a history of recent mumps or parotitis; mumps orchitis is unilateral in 70% of ca ses. In 30% of cases, contralateral testicular involvement follows a few days later. This c ondition is rare in post-pubertal boys. Bacterial orchitis is usually associated with an ep ididymitis. \200 Epididymitis \200 \200 Usually associated with concomitant orchitis. In children epididymo-orchitis is usually ass ociated with a urinary tract infection: infected urine re \202 uxes down the vas. Structur al abnormality in the renal tract should be excluded. Epididymo-orchitis presents with feve r, urinary symptoms, and scrotal pain. In sexually-active adolescents epididymo-orchitis ma y be caused by gonorrhea or Chlamydia. Epididymo-orchitis should be managed with antibiotic s once urine has been sent for culture. Adolescents should be screened for sexually transmi tted infection (see b p.801). \200 Testicular trauma A direct blow to the scrotum may rupture a testis. The scrotum is too pai nful to examine clinically and a gentle US examination should be per- formed. If the testis is disrupted surgical exploration and repair is neces- sary to prevent atrophy. If the blo w is severe a urethral injury should be suspected and, if necessary, excluded by urethrogra phy. 23_McClure_23.indd 877 11/14/2012 3:30:25 PM CHAPTER 23 Pediatric surgery 878 Undescended testes (cryptorchidism) The testes descend through the inguinal canals into the scrotum during the \201 rst trimester. Cryptorchidism (Fig. 23.20) is seen in 3% of full -term newborn boys and 1% of boys at 1yr. Spontaneous descent may occur in the \201 rst 6 mths, but is unlikely after this. Cryptorchidism is more common in premature infants. Clinical aspects Undescended testes are subdivided into the following. \200 Palpable undescended testes (80%): usually at the external inguinal ring. These testes can be bought down into the scrotum with an orchidopexy performed through an inguinal incision. testes (20%): intra-abdominal, inside the inguinal canal, or Impalpable absent. There is r isk of malignant degeneration in an intraabdominal testis (1:70, compared with 1:5000 for n ormal testis). Laparoscopy is the investigation of choice for an impalpable testis. US, CT/ MRI are not helpful. If the vas and vessels enter the deep inguinal ring (30%), an inguinal orchidopexy is indicated. If the vas and vessels end blindly at the deep ring (30%), then the testis has torted in utero and has resorbed. No further action is necessary. If a testi s is seen inside the abdomen then it must be removed or bought down with a two-stage orchid opexy. When should boys be referred to a surgeon? \200 If an undescended testis is noted on routine postnatal check, this should be documented in the medical records. Initial follow-up should be with the GP because the majority of these testes will descend during the \201 rst 6mths of life. If still undescended at 6mths, ref er to a pediatric surgeon. Palpable UDTs at external inguinal ring (commonest) Impalpable UDTs (either in inguinal canal or intra- abdominal) Small scrotum Fig. 23.20 Undescended testes (UDT). 23_McClure_23.indd 878 11/14/2012 3:30:25 PM RETRACTILE TESTES 879 Retractile testes The cremasteric muscle is overactive and the testes retract into the groi n. The scrotum is well developed and the parents may notice that the testes are in place wh en the child is in a warm bath. Examine in a warm environ- ment. The testes can be manipula ted into the scrotum and will remain there until the cremasteric re \202 ex is stimulated. Surgery is not necessary. Hypospadias Hypospadias affects 71/350 male births. Characterized by an abnormal position o f the external urethral meatus and is classi \201 ed according to the location of the meat us (penis down to the scrotum; see Fig. 23.21). Severe forms of hypospadias may be associat ed with chordee \200\224a ventral curva- ture of the penis. The most common consequences of hypospadias are dif \201 culty urinating while standing and a cosmetic appearance of the penis that differs from that of other boys. Sexual function is not affected unless chordee, which may cause painful erections, is present. Hypospadias advice \200 \200 \200 \200 Make sure you document the diagnosis in the notes. Tell the parents not to circumcise the c hild. Give the parents a letter stating this advice. Refer the child to a pediatric surgeon . Surgery Surgical correction involves straightening of any chordee and reconstruc- tion of t he urethra to the glans. This may involve tubularizing skin from the prepuce so circumcisio n is contraindicated. The correction can be completed in one or more operations during earl y childhood. Common (60%) Glanular The foreskin is deficient ventrally in hypospadias Coronal Distal penile Proximal penile Penoscrotal Scrotal Perineal Uncommon (30%) Rare (10%) Chordee is a ventral curvature of the penis associated with proximal hypospadias Fig. 23.21 Classi \201 cation of hypospadias. 23_McClure_23.indd 879 11/14/2012 3:30:25 PM CHAPTER 23 Pediatric surgery 880 Phimosis and paraphimosis The foreskin develops in utero as a protuberance of the penile ep idermis, which grows forwards over the glans and adheres to it. The prepuce is normally non -retractable during early childhood. During this period it is very common for parents to no tice that the child \200\231s prepuce balloons dur- ing micturition. It is also very common for boys to complain of intermit- tent redness and discomfort from the prepuce. This is ra rely the result of bacterial or candidal infection, but simply a chemical irritation from u rine under the foreskin. These symptoms are self-limiting and resolve during childhood with out intervention (i.e. circumcision). Circumcision There are few medical indications for circumcision in boys. The majority of no n-religious circumcisions performed in the UK are unnecessary (i.e. nor- mal non-retractile foreskins). Genuine indications for circumcision are: \200 Phimosis: this is almost exclusively caused by balanitis xerotica obliterans (BXO, or liche n sclerosis) which is an uncommon scarring dermatitis characterized by a thickened indurate d whitish appearance of the tip of the prepuce. BXO affects 2% of boys by the age of 17yrs and is very rare in those aged <5yrs. Paraphimosis: becomes stuck behind the glans. The gla ns becomes swollen and oedematous. The paraphimosis should be reduced under general anesthe sia and circumcision scheduled a few weeks later to prevent recurrence. Recurrent the prepuce retracts as the boy gets an erection and balanitis: this is rare. Balanitis/balanoposthitis Balanoposthitis is acute in \202 ammation of the glans and fores kin associated with a purulent discharge from the preputial ori \201 ce. This condition af fects 4% of boys, mostly between 2 and 5yrs of age. Recurrent episodes rare. \200 \200 UTI: Treatment: 5-day course of oral trimethoprim or amoxycillin is appropriate. Topical an tibacterials or antifungals are of no value. Staphylococcus aureus is the most common cause. Priapism Priapism is a persistent painful erection. The commonest cause in boys is trauma, usually a fall astride injury to the perineum. Occasionally, priapism is a presenting sympt om of acute leukemia or SCD. Treatment is usually conservative, but may need intervention i n SCD (b p.621). 23_McClure_23.indd 880 11/14/2012 3:30:26 PM PENILE TRAUMA 881 Penile trauma Most penile trauma is iatrogenic as a result of circumcision. Bleeding post- circumcision usually needs exploration under anesthetic. Clotting should be checked to excl ude hemophilia in infants. Entrapment of the foreskin in trouser zips is occasionally seen. \200 If the prepuce is caught between the teeth of the zip, then release can be achieved by cutt ing across the zip and separating the edges. This can usually be managed in casualty. Entra pment between the zip slide and the teeth is more complicated because the slider has to be prised off with bone cutters. This is best performed under anesthetic. Imperforate hymen An imperforate hymen usually presents within a few days of life with a lo wer abdominal mass, sometimes associated with urinary retention. Intrauterine stimulation o f the infant \200\231s cervical mucous glands by ma- ternal oestrogens causes accumulation of secretions (mucocolpos). The imperforate hymen can be seen bulging through the introitus and treat- ment consists of incising the hymen. Occasionally, an imperforate hymen is not detected in the newborn period and presents at puberty with p amenorrhoea or a painful lowe r abdominal mass from a haematocolpos. Treatment again comprises incision of the hymen and should be per- formed under general anesthesia. Labial adhesions in infants Labial adhesions are common in female toddlers. Nappy rash and expo- sure to urine cause a chronic irritation of the fragile labia which adhere. There is invariably a small opening anteriorly through which urine escapes. Labial adhesions cause n o symptoms, but they are a major source of anxi- ety to parents. Treatment is best deferred until the child is out of nappies. Topical application of oestrogenic cream for 2wks will result in separation of most adhesions but occasionally gentle separation under anesthetic may be necessary. 23_McClure_23.indd 881 11/14/2012 3:30:26 PM CHAPTER 23 Pediatric surgery 882 Miscellaneous conditions Tongue-tie Common and rarely causes symptoms. Tongue-tie does not cause lisp, and is most de \201 nitely not responsible for eating problems in an older chi ld. Division of a tongue-tie does not alter the natural history of either con- dition. Tong ue-tie does affect the ability of newborns to breastfeed and division of the lingual frenul um within the \201 rst week of life will correct this problem. Bottle feeding is not affe cted (b p.146). Dermoid cysts Common in children (Fig. 23.22). Dermoids are non-tender, mobile subcu- taneo us cysts \201 lled with keratin, hair follicles, and sebaceous glands. They enlarge slowl y and should be treated by excision. Dermoid cysts occur most frequently along lines of emb ryological fusion, such as lateral corner of the eyebrows (external angular dermoid), midli ne of the neck, over the bridge of the nose, and suprasternal notch. Thyroglossal duct cysts (TDC) Present with midline swelling in the neck, just below the hyo id bone. The swelling rises with tongue protrusion and swallowing. TDCs develop from epithe lial remnants left after descent of the developing thyroid from the foramen caecum at the b ase of the tongue. TDCs gradually enlarge and eventually become infected, which makes excis ion more dif \201 cult. Treatment is surgical removal of the central portion of the hyoid bone along with the cyst and track. Branchial remnants Branchial remnants persist from the branchial clefts during embryogenesi s of the head and neck. Anomalies of the second branchial cleft are by far the most common. They can be a cyst, a sinus tract, or rarely a \201 stula. \200 sinuses: present as small cutaneous openings along the Branchial anterior lower third border of the sternocleidomastoid muscle that discharge mucu s (Fig. 23.23). They can communicate with the tonsillar fossa (branchial \201 stula). Man agement is excision to prevent infection. Branchial the sternomastoid. The differential inc ludes cystic hygroma, which is more common, and the treatment is surgery. cysts: uncommon neck swellings along the anterior border of Cystic hygroma (CH) A congenital malformation of the lymphatic system. CHs present in early childhood as soft multilocular cystic swellings that often appear after an intercurrent vi ral infection. CHs are more often found in the neck and axillae, although they can occur an ywhere, including inside the abdomen or thorax. Large cervical cystic hygromas may present at birth with air- way obstruction. Small CHs require no treatment. Large lesions in \201 ltrate the surrounding tissues making complete surgical excision impossible. Intralesional injection of OK432 (lyophilized product of Streptococcus pyo- genes) is an alternative to s urgery in some cases. 23_McClure_23.indd 882 11/14/2012 3:30:26 PM MISCELLANEOUS CONDITIONS 883 Congenital torticollis See also b p.127. Within the \201 rst weeks of birth a small swell ing in the baby \200\231s neck is noticed. A sternomastoid tumor is a palpable area of \201 bro- sis in the lower sternomastoid muscle (SM) and is a transient phenome- non that w ill resolve after a few months. Sometimes there is a history of dystocia. Shortening of the SM results in torticollis with rotation and tilting of the head to the opposite side. Mana gement is conservative in most cases with passive exercises to achieve full neck movements. Hemifacial atrophy and strabismus may develop unless full movement is restored. Occasional ly it is necessary to divide the SM, but this is no substitute for physiotherapy. External angular dermoid cyst Fig. 23.22 External angular dermoid cyst. Typical pin-hole opening of a branchial sinus Fig. 23.23 Branchial sinus. 23_McClure_23.indd 883 11/14/2012 3:30:26 PM CHAPTER 23 Pediatric surgery 884 Perioperative care Elective children All children need to have a history and examination: \200 \200 \200 The presenting complaint should be documented and con \201 rmed. Previous medical history, medication, and allergies must be recorded. A brief clinical examination should be perform ed. In the case of undescended testes, hydroceles, and inguinal hernias a mark should be ma de on the child \200\231s thigh to document the side for operation (away from the surgical \201 eld to prevent tattooing of the wound). If the child is unwell with an intercurrent illness, discuss with the anesthetist who may decide that the child is un \201 t for anest hesia. Blood tests These should be kept to a minimum. Children undergoing major surgery should hav e the following done: \200 Hemoglobin checked and blood cross-matched, according to the nature of the operation (usual ly one unit of blood is suf \201 cient). Urea and electrolytes should be checked pre-opera tively in children taking diuretics, children in renal failure, and children receiving IV \202 uids. Children at risk of sickle cell disease or thalassaemia should be screened in o utpatients before admission. Fasting prior to elective surgery This is essential for safe induction of anesthesia. Recom mendations from the Association of Pediatric Anesthetists are given in Box 23.2. Box 23.2 Minimum fasting times prior to elective surgery \200 \200 \200 \200 Solid food: 6hr Formula milk: Breast milk: Clear \202 uids (dextrose solution, water): 6hr 4hr 2hr Anesthetist The anesthetist will visit pre-operatively and discuss anesthesia and post-oper ative analgesia with the child and parents. In some instances pre- medication may be approp riate. \200 IV access will be obtained during induction of anesthesia and it is sensible to pre-empt th is by applying local anesthetic ointment (e.g. EMLA \204 ) under occlusive dressings to the back of the child \200\231s hands or feet, provided a suitable vein is visible. Some anest hetists are happy for children to come down to theater wearing their pajamas; others may re quest a theater gown. Pediatric anesthetists generally encourage one parent to accompany th e child to the anesthetic room and many will be happy for the parent to remain with the chi ld during induction. 23_McClure_23.indd 884 11/14/2012 3:30:26 PM PERIOPERATIVE CARE 885 Newborns Pre-operative resuscitation and preparation are essential if the outcome of surger y is to be successful. Newborns with congenital malformations will be admitted to a neonata l intensive care unit. Routine preparation This should include: \200 \200 \200 Intramuscular vitamin K. FBC to determine the hemoglobin. Cross-matching blood. Many labora tories require a sample of maternal blood for typing and this should accompany the baby if the mother is unable or un \201 t to travel. Echocardiography Babies with OA and anorectal malformations should undergo echocar- diograp hy before surgery because of the possible cardiac defects in the VATER association. Renal imaging Provided the baby passes urine (indicative of functioning nephrons) renal ima ging can be arranged electively. Anuria necessitates a renal US scan to exclude renal agene sis. Intestinal obstruction Babies will require: IV \200 \202 uid: normal maintenance is required. Babies with gastroschisis lose \202 uid and heat rapidly from the exposed bowel. The baby \200\231s abdomen should be wr apped circumferentially in Cling \201 lm \204 (this does not need to be sterile). Regular bolus infusions of 4.5% albumin solution should be given before closure of the defect. NG \200 decompression: a wide bore NGT is necessary to empty the stomach (8 or 10 French gauge). The NGT should be aspirated every hour and left on free dra inage. NG aspirates should be replaced mL for mL with 0.9% saline with 20mmol KCI/L, in add ition to maintenance \202 uids. Biochemistry vomiting (e.g. pyloric stenosis). and acid \200\223base balance: necessary in babies with prolonged 23_McClure_23.indd 885 11/14/2012 3:30:26 PM CHAPTER 23 Pediatric surgery 886 Consent for surgery See also b pp.1036 \200\2231039. Consent for surgery: clinical practice The best person to obtain consent is the surgeon performing the operation Children \200 Whenever possible the procedure should be explained to the child in language that he/she ca n understand Young children are not generally interested in alternative treatments and risk . They are reassured to know that their parents will be with them when they go off to sleep Children are interested to know how long the operation will take, how they will feel after wards, and how long they will get off school Parents Informed consent must be sought from the parents. This must include: \200 An explanation of the diagnosis and the proposed operation, along with alternative treatmen ts, risks and bene \201 ts, and the likely outcomes It is prudent to discuss potential com plications and provide an estimate of risk. The risk of adverse reactions to general anesth esia in \201 t, healthy children is between 1/10,000 and 1/100,000, which is comparable w ith the risk of injury crossing a road Emergency \200 \200 In an emergency it is justi \201 able to treat without parental consent It must, however, be documented clearly that the child \200\231s life is in danger and that attempts have bee n made to contact the parents Ensure that entries in the records are signed, timed, and dat ed Verbal consent from the parents is acceptable in an emergency and this should be recorde d on the consent form \200 23_McClure_23.indd 886 11/14/2012 3:30:26 PM CONSENT FOR SURGERY 887 23_McClure_23.indd 887 11/14/2012 3:30:26 PM CHAPTER 23 Pediatric surgery 888 Post-operative care: \202 uids Day case children Children admitted for day case surgery w ill return to the day care ward from the theater recovery area once they are alert, able to maintain their airway, haemodynamically stable, and comfortable. The presence of a par- en t in the recovery room is usually bene \201 cial. Oral \202 uids can be offered in most cases on return to the ward and, if tolerated without nausea, followed by food. Within a fe w hours most children can be discharged home. Major surgery Following major surgery children will return to the ward or intensive care un it. The operation note should include speci \201 c instructions regarding an- tibiotics, c atheters, IV \202 uids, etc. \200 Post-operative There is now a general directive to use 0.45% sodium chloride with 5% dextro se or 0.9% sodium chloride for post-operative \202 uid because the risk of hyponatraemia is minimized. The rate of infusion should be adjusted according to the weight of the child. Potassium chloride 20mmol/L should be added to \202 uids after the \201 rst day. Nasog astric chloride with 20mmol KCI/L. It is easy to underestimate \200\230third space losses \200\231 (i.e. \202 uid translocating into the peritoneum, bowel, or chest) after major s urgery and this volume of \202 uid should be added to the maintenance requirements and \202 uid given to replace continuing losses (e.g. NG aspirates). If the child has cool peri pheries and a prolonged capillary re \201 ll time the situation will almost always improve after infusion of 20mL/kg of additional \202 uid (0.45% sodium chloride with 5% dextrose , 0.9% saline, 4.5% albumin, and plasma substitutes are all used in practice). Hemoglobin: Blood transfusion is to be avoided whenever possible and, with the exception of oxygen depe ndent children, a moderate post-operative anemia is well tolerated. If transfusion is neces sary (i.e. hemoglobin <7.0g/dL) every effort should be made to ensure that the child is onl y exposed to blood from one donor even if this means that the volume of blood transfused is less than originally calculated. Routine co-administration of diuretics is not necessary i n the surgical patient. Biochemistry: IV \202 uids should have blood U&E measured daily. Frequent adjustments to the electrolyte content and rate of infusion may be necessary. \202 uids: following abdominal surgery most children will have a Oral paralytic ileus for 3 6 \200\22348hr. After this period, oral intake will resume and IV \202 uids can be discon tinued. If more prolonged IV \202 uid therapy is necessary consideration should be given to parenteral nutrition. IV \202 uids: will depend on the nature of the surgery. aspirates: should be replaced mL for mL with 0.9% sodium check the hemoglobin on the \201 rst post-operative day. children with high urinary or high stoma losses receiving 23_McClure_23.indd 888 11/14/2012 3:30:26 PM POST-OPERATIVE CARE: FLUIDS 889 Nasogastric tubes NGTs usually inserted to keep the stomach empty. In the pre-operative per iod this is useful in a child with an intestinal obstruction. A bile-stained aspirate signi \201 es an intestinal obstruction and emptying the stomach will prevent the child from vo miting. Unless otherwise instructed, the NGT should be aspirated every hour and the aspirat e replaced intravenously mL for mL with 0.9% saline containing KCI 20mmol/L. \200 Common practice to insert a NGT in theater in a child undergoing abdominal surgery that is likely to result in a paralytic ileus. Post-operative management is the same as pre-operati ve. As the ileus resolves after 24 \200\22336hr the volume of the NGT aspirate will decreas e and it will become clear. At this stage the NGT can usually be removed and oral \202 ui ds resumed. In most cases prescription of the volume of oral \202 uid is not necessary, b ut restricting the child to water only for the \201 rst 24hr effectively limits the amoun t they ingest. Transanastomotic tubes Following repair of OA in the newborn the surgeon will commonly plac e a \200\230transanastomotic tube \200\231 (TAT). The purpose of the TAT is to allow early resumption of enteral nutrition. \200 Do not attempt to repass a TAT that has been removed inadvertently without seeking advice f rom the surgeon. Perforating an anastomosis is likely to land both you and the baby in trou ble! Newborns and infants Newborns and infants <44wks post-conception should be transferred to a neonatal or special care baby unit post-operatively. The risk of post- operative apnoea af ter general anesthesia is relatively high. Monitoring for a minimum of 24hr post-anesthetic should include routine nursing observations of: \200 temperature; \200 pulse; \200 r espirations; \200 pulse oximetry; \200 apnoea monitoring. 23_McClure_23.indd 889 11/14/2012 3:30:27 PM CHAPTER 23 Pediatric surgery 890 Post-operative care: analgesia See also b p.1018. Analgesia for day cases Operations are painful and analgesia is essential. \200 In many cases, local anesthetic blocks or wound in \201 ltration will provide complete ana lgesia for several hours. After this simple analgesics, such as paracetamol or ibuprofen ar e usually all that is required. For older children codeine and/or diclofenac may be necessa ry. A prescription for 2 \200\2233 days should be given prior to discharge. Analgesia for major surgery After major surgery stronger analgesia is required for a longer period. This applies to neonates, as well as older children. Continuous epidural infusions of local anesthetics There are many advantages to local or re gional analgesia and continuous epidural infusions of local anesthetics (e.g. bupivicaine) work particularly well after major abdominal or thoracic surgery. \200 Epidural infusions are not without risk. It is essential that close nursing supervision is maintained (i.e. vital signs and level of the epidural block). In many hospitals there is a \200\230pediatric pain team \200\231 who supervise the epidural. If this is not available , close liaison should be maintained with the anesthetist responsible. If the level of anes thesia seems to be rising to the upper thoracic dermatomes the infusion should be stopped p ending advice. If the analgesia is inadequate advice should be sought before either removin g the epidural catheter or starting opiates. Continuous IV infusion of morphine Infusion of morphine or other opiates is another very ef fective method of post-operative analgesia. For older children, this may be in the form of a patient-controlled analgesia pump with a button the child can press to obtain an incremen t of analgesic. \200 Most hospitals will have guidelines on the use of analgesics for children that should be fo llowed. \200\230Pain ladders \200\231 providing options for analgesics of increasing poten cy are becoming common. It is not acceptable to leave a child in pain and it is simply untr ue that administering strong analgesics will mask clinical signs. Peritonitis can be detect ed reliably in a child who has received morphine. 23_McClure_23.indd 890 11/14/2012 3:30:27 PM POST-OPERATIVE CARE: DRAINS AND WOUNDS 891 Post-operative care: drains and wounds Chest drain removal An adult can be asked to suspend respiration in full inspiration before removal of a chest drain. Children will not co-oper ate with this. \200 The best strategy is to remove the drain quickly. Then cover the site with an air-tight tra nsparent dressing (e.g. Tegaderm \204 ). The dressing should remain undisturbed for 48hr af ter which time the wound can be left open. Purse-string sutures are painful and not necessa ry. It is not necessary to take a chest radiograph immediately after the drain has been rem oved provided the child is clinically well. \200 Wound care Routine closure of skin wounds in children is by subcuticular suture. The suture runs along below the surface of the wound and provides a neat and water-tight closure. Inv ariably an absorbable suture is used (e.g. Vicryl \204 or PDS \204 ). \200 Dressings are a matter for individual preference. If dressings are used it is wise to keep the wound dry until the dressing is removed. If no dressing is used, then keep the wound dr y for 24 \200\22348hr. The appearance of clean surgical wounds should improve progressively each day after surgery. Parents should be asked to report increasing redness or tenderness so that the wound can be reviewed. \200 Advice after discharge from hospital Parents should be given clear simple advice before dis charge from hospi- tal regarding analgesia, wound care, and post-operative follow-up. Ideal ly, written information should also be provided. \200 Following within 24hr. They should be kept off school for 2 \200\2233 days and be excused s ports activities for 14 days. Routine follow-up of children has now been abandoned by most surgeons. This is, however, a matter of personal preference. Convalescence return to school and resumption of sporting activity depends on the operation. minor day case: children will generally be back to normal following major surgery: speci \201 c advice relating to 23_McClure_23.indd 891 11/14/2012 3:30:27 PM This page intentionally left blank 893 Chapter 24 Special senses Common presentations 894 Hearing assessment 896 Childhood deafness 898 Disorders of the ear 900 Common disorders of the nose 902 Disorders of mouth and tongue 904 Visual development and examination 905 Vision assessment 906 Vision screening in the UK 908 Squints (strabismu s) 910 Ametropia (refractive disorders) 911 Amblyopia 911 Visual impairment 912 Nystagmus 9 13 Disorders of the eye: infection and in \202 ammatory 914 Eye foreign body 916 Cataract 916 Glaucoma 917 Orbit and eyelids 918 Back of the eye problems 920 Trauma 922 24_McClure_24.indd 893 11/14/2012 3:31:57 PM CHAPTER 24 Special senses 894 Common presentations The red eye Careful evaluation is needed when presentation is acute an d there is associated pain, swelling, constant lacrimation, or blurred vision. Causes \200 URTI. \200 Viral conjunctivitis. \200 Irritant conjunctivitis, e.g. chlor inated swimming pool. \200 Bacterial conjunctivitis. \200 Stye (infection of eyelash fo llicle). \200 Chalazion (meibomian or tarsal cyst). \200 Other: uveitis. corneal laceration/ulcer/keratitis; FB; peri-orbital cellulitis; Differential diagnosis \200 Redness of entire eyelid or swollen eyelid: \200 \200 Associated eye pain or constant e ye tearing, blinking: \200 corneal ulcer; \200 HSV keratitis; \200 eye FB ( Blurred v ision: Infant under age 1mth: Painless red eye with good vision: Uncomfortable red eye with good vision: \200 \200 Painful red eye with photophobia: \200 \200 \200 \200 \200 Eyelid redness and oedema: \200 \200 \200 \200 b p.919); peri-orbital cellulitis ( acute ethmoiditis. b p.916). \200 \200 \200 uveitis (b p.915). gonorrhea (b p.914). sub-conjunctival hemorrhage conjunctivitis \200\224viral, bacterial, allergic, or chemical; episcleritis corneal or sub-tarsal FB; corneal abrasion; corneal ulcer/keratitis; anterior uveitis (irit is); scleritis. localized \200\224 generalized \200\224 acute allergic conjunctivitis; herpes simplex/herpe s zoster ophthalmicus. stye, meibomian cyst, dacryocystitis (lacrimal sac abscess); pre-septal or orbital cellulitis; 24_McClure_24.indd 894 11/14/2012 3:31:57 PM COMMON PRESENTATIONS 895 Ear: pain and discharge Ear discharge (otorrhoea) may be due to drainage of blood, ear wax, pus, or \202 uid from the external or middle ear. \200 \200 \200 \200 \200 \200 \200 Otitis externa. Eczema and other skin irritations. Foreign object impaction. Otitis media. Mastoiditis. Perforated eardrum. Head injury \200\224CSF leak. Earache (otalgia) can be a symptom of the conditions noted above. However, it may be the re sult of pain referred from pathology at another location (referred otalgia): \200 \200 \200 \200 \200 Sinusitis Parotitis. Teeth and jaw (impacted molars, dental caries). Acute tonsillitis;. Or opharyngeal tumors. 24_McClure_24.indd 895 11/14/2012 3:31:57 PM CHAPTER 24 Special senses 896 Hearing assessment A fetus will respond to sound in the latter part of pregnancy (from 3rd trimester). At birth, the baby will react to noise with a marked preference for voices. Hearing screening See also b p.560. Speci \201 c screening questions can be asked when evaluating hearing: Birth 12wks: \200 \200 : does baby startle to loud noise? Does baby quieten to mother \200\231s voice even when mother cannot be seen? Does baby quie ten to prolonged loud noise? Does baby settle to a musical toy? \200 5mths: \200 \200 7mths: \200 \200 9mths: \200 \200 11mths: Does baby smile to familiar voice? Does he/she take turns to vocalize when spoken to? Does baby turn to look towards a new sound? Does he/she make tuneful vocalization? Does baby recognize own name? Does baby recognize and react to familiar tunes and music? Will baby react to calling from out of sight? The early detection of hearing loss is important. Deafness impairs speech and language deve lopment, cognitive development, and socialization. A baby who does not startle when parents come into view may not have heard them approach due to deafness. These children need urgen t audio- logical assessment along with children who show absence of appropriate vocalizatio n by age (see bullet points in Hearing screening).