Know Your Problem


What is an anorectal anomaly?

This is a disorder affecting the anus and the rectum, the last part of the digestive system. After food has been digested it passes through the small bowel into the large bowel. The faeces (stools) are stored in the rectum until the muscles receive a message from the brain to empty the bowel. The faeces then pass out through the anus.

There are two types of anorectal anomaly - low anorectal anomaly and high anorectal anomaly. A low anorectal anomaly is where the anus is closed over, in a slightly different position or narrower than usual. A high anorectal anomaly is where the bowel has a closed end and does not connect with the anus or it connects with another part of the body through a passage called a fistula.

An anorectal anomaly can be associated with other problems, but the doctor will examine your child closely to check if this is the case.

What are the symptoms of an anorectal anomaly?

Symptoms vary according to the type of anorectal anomaly. They are classified into two types (high and low) depending on where the bowel ends.

If your child has a low anorectal anomaly, faeces cannot be removed from the body as usual, and so builds up in the bowel. Your child will not be able to pass meconium - the dark faeces passed in the first few days of life. The build up of faeces in the bowel can cause a swollen abdomen and vomiting.

Low Anorectal Malformations Anorectal Malformation without fistula

If your child has a high anorectal anomaly with a fistula, the faeces will be able to pass out of the body, usually through the vagina in girls or through the urethra in boys.

Anorectal Malformation without fistula How is an anorectal anomaly diagnosed?

An anorectal anomaly is usually diagnosed soon after birth, on examination, or when the baby fails to pass meconium. The doctor may suggest scans to give a clearer picture of the type of anorectal anomaly and whether there is a fistula.

What causes an anorectal anomaly and how common is it?

An anorectal anomaly happens when the bowel does not form properly while the baby is developing in the womb. We do not know exactly what caused this, but it was not due to anything that happened during pregnancy. About one in 3,000 babies are born with an anorectal anomaly, with more boys than girls affected.

What treatments are available and are there any alternatives?

The treatment depends on the type of anorectal anomaly. All types of anorectal anomaly will need an operation under general anaesthetic - usually an ‘anoplasty’ if your child has a low anorectal anomaly or a series of operations if your child has a high anorectal anomaly.

The first operation is to create a loop stoma (an artificial way of disposing of waste matter) usually in the days after birth.

The second is a ‘pull-through’ operation to join the bowel to a newly created anus. This usually happens when your child is a few months old and has gained weight.

The final stage is to close up the stoma. This happens when your child’s bowel and anus is working well a few weeks after the second operation. The three operations are usually completed by the time your child is six months old. There are no alternatives to these operations, as your child needs to be able to pass faeces to prevent it building up in the bowel, which could lead to discomfort and infection.

What does the operation involve?

Anoplasty - the surgeon will open up the anus (if it was closed over), move the anus (if it was in a slightly different place to usual) or widen the anus (if it was narrower than usual).

Creation of loop stoma - the surgeon will bring the bowel to an artificial opening in your child’s abdomen (stoma). ‘Pull-through’ operation - the surgeon will create a new anus and then separate the bowel from the fistula (if there is one) and bring it down to join the newly created anus. He or she will then close up the fistula. Your child will continue to use the stoma so that the bowel and anus can rest and heal.

Closure of loop stoma - the surgeon will disconnect the the bowel from the stoma and close it to form a fully working bowel.

What happens afterwards?

Your child will come back to the ward to recover. We will keep your child as comfortable as possible, by giving regular pain relieving medications. For the first few days, the pain relief will usually be given through a ‘drip’ and then, when your child is more comfortable, in the form of medicines to be swallowed.

For the first few days, your child will need a ‘drip’ of fluids until he or she feels like eating and drinking again. This will also allow the bowel to rest and start to heal. After a while, you can start to feed your child again, starting with small amounts, and increasing the amount as he or she tolerates it.

If your child has had a new anus created, you may be asked to stretch (dilate) it using a probe called a dilator. The doctor will show you how to do this before you go home. You will need to start with a small size dilator and gradually increase the size until the anus is the right size If your child has had the stoma and mucous fistula created, the nurses will teach you how to look after them both. We will make sure you feel confident before you go home

What is the outlook for children with anorectal anomaly?

The outlook for children with anorectal anomaly depends on the type of abnormality. Your child may need extra bowel training at a later stage to learn when and how to empty his or her bowels. He or she may also need some extra help in the form of enemas or washouts, but these will be explained to you if they are needed. However, some children continue to have bowel problems for many years after the operations, but this depends on the original severity of the anorectal anomaly.

Your child will need regular check ups with your doctor at the hospital. These happen regularly until your child is a teenager.

Some girls who have had an anorectal anomaly may be better having a caesarean section rather than normal childbirth. This will put less strain on the operation site and is less likely to cause problems in the future.

My child is complaining of pain. What can I do?

It is quite normal for your child to feel some discomfort for the first 48 hours after his or her operation. Usually medicines are given to relieve any pain. If stronger medications are needed they would be given either intravenously by the nurses.

Pain relief medicines will be given at the time of discharge. If, when you get home, you feel that your child needs more powerful pain relief, you should call your doctor. You can also telephone the hospital for advice. Always follow the instructions that have been given to you. Never give your child more than the recommended dose.

Is there anything else I can do to make my child feel better?

If the skin is sore about the site of the operation, wearing loose-fitting clothes will make your child feel more comfortable. As well as giving pain relief medicines, distracting your child by playing games, watching TV or reading together can also help to keep your child’s mind off the pain.

My child does not want to eat. Should I be worried?

After the anesthetic, your child may feel sick for 24 hours. You should encourage your child to drink but do not force him or her to do so. As long as your child is drinking, it does not matter if he or she does not feel like eating for the first couple of days.

Are there any activities my child should avoid?

You should keep your child away from school or nursery for a week after the operation. After certain types of operation, your child should not ride a bicycle or play contact sports for about a week to ten days. Doctors will give you relevant instructions regarding the same according to the type of operation your child had at the time of discharge.

What are bowel washouts and why does my child need them?

Bowel washouts are a method of dealing with constipation or with soiling, which is the leakage of faeces (stools) other than during a bowel movement. There are many reasons why a child may soil including:

  • Congenital (present at birth) abnormalities affecting the anus and rectum
  • Neuropathies (nerve supply problems) as a result of spinal abnormalities like spina bifida.
  • Overflow incontinence which is often seen in children with severe constipation.
  • Other methods will usually be tried first, and may include bowel training, dietary changes, medications taken by mouth, and medications taken rectally (enemas or suppositories). If these methods fail, doctors may recommend bowel washouts using an antegrade colonic enema (ACE). This can also be called the Malone or MACE method.

What do they involve?

Before you can start doing bowel washouts, your child will need an operation under general anaesthetic. This operation creates a channel (usually using the appendix) into the large bowel at a point called the caecum. The fluid used to wash out the bowel can then be inserted easily. This fluid flushes the faeces out through the rectum in the usual way.

What does the operation involve?

ACE operations are carried out using keyhole surgery (laparoscopy) or open surgery. Depending on the surgical method used, the surgeon may disconnect the appendix from the caecum and then reconnect it. Alternatively, he may leave the appendix in its original position and bring the end up to the wall of the tummy. In both methods, the end of the appendix is opened up to form a channel from the tummy wall to your child’s large bowel. This is called a stoma (artificial opening).

If your child has already had his or her appendix removed or if it is not suitable, the surgeon may need to use a piece of the small bowel to create the passage.

Are there any risks?

All treatments carry an element of risk, but this must be balanced against the quality of life without treatment.

What happens afterwards?

Your child will come back to the ward to recover. For the first day or two, he or she will have a drip giving fluids and medication until the bowel starts to recover. The drip will be removed when your child starts eating and drinking again.

The surgeon will have inserted a catheter (thin, plastic tube) into the stoma to keep it open. This should stay in place for seven to fourteen days after the operation. In some cases, the catheter may need to stay in place for longer. This varies from child to child.

When your child has recovered from the operation, and eating and drinking again, the nurse will teach you how to do bowel washouts using the ACE. When you are confident, you and your child will be able to return home.

Looking after the stoma

You should insert a catheter into the stoma each day to keep it open, even if no washout is planned for that day. We will give you two sizes of catheter, the size you will be using to do the washout and one a size smaller. Alternatively, you can insert the small silicone plug into the stoma.

The stoma can shrink a little after the operation, but this usually settles down when you use the catheter. On rare occasions, the stoma may need stretching while your child is under a general anesthetic.

Starting washouts

Nurses will teach you how to do the bowel washouts when the stoma has settled down, usually between two and three days after the operation. If you and your child have returned home, you will need to come back to the hospital for teaching. You will have a lot to learn about bowel washouts and it may feel daunting at first, but will quickly become easier.

The washout solution varies from child to child, depending on his or her needs. The amount of fluid also varies and is worked out according to your child’s age and size. For the first few weeks, the make-up of the solution may need changing to get the best result.

It may take about six to eight weeks to get into a routine and for the washouts to work effectively. It can help to keep a daily diary of progress. You will also need to keep in contact with your doctor for the first few months until you and your child have settled into a regular washout pattern.

The condition of having an additional little finger on one or both hands is very common, especially in certain ethnic groups. Usually it is inherited, with a 50 per cent or one in two chance of it happening if the parents have it. At other times, it happens spontaneously, without anyone else in the family being previously affected. When your child has an additional little finger, there is a 50 per cent or one in two chance of his or her children also being born with one.

Can it cause any problems?

Sometimes the extra finger is well formed, but more commonly it has a narrow base or stalk and is dangling from the edge of the normal hand or leg. The place where the extra finger joins the hand might be bony or it could just be a soft stalk. If the extra finger has a narrow stalk, it can twist, cutting off the blood supply so it turns blue or black. The extra finger has a nerve supply so it will be painful if this happens.

How can the extra little finger be corrected?

The extra little finger(s) can be removed in a short operation.

Are there any risks?

It is a relatively safe procedure with no major complications. There will be a scar where the extra finger was removed, but this is quite small. It usually fades gradually with time, so that it is less noticeable but it will always be there. What would happen if my child did not have the operation? The extra little finger should not cause any problems if it is taped securely to the next finger. However, most parents ask for the extra finger to be removed, as it can lead to unwanted attention for their child as they grow older.

What does the operation involve?

Once the anaesthetic has started to work, the surgeon will remove the extra finger, stopping its blood supply. He will stitch the operation site closed and cover it with a dressing. The operation lasts around 15- 20 minutes to remove one extra finger and slightly longer if an extra finger needs to be removed from both hands. When you get home Keep the operation site dry and covered with the light dressing for one week. All the stitches used are dissolvable and will begin to rub off in around two weeks. The light dressing can be gently peeled off after a week or so. After two weeks, if the operation site has healed, you can massage the scar with coconut oil/ antiseptic ointment twice a day until the scar has faded.

Anal fissures are tiny tears in the skin around the anus and can be painful. They usually develop as a side effect of constipation. Constipation is the condition where a person passes stools less frequently than usual and the stool is harder, drier and painful to pass.

What causes anal fissures?

They usually develop when your child is constipated. The sphincter (ring of muscle) around the anus stretches to let the hard dry stool pass, and the tissue around the anus may tear as a result.

What are the signs and symptoms of anal fissures?

Anal fissures are usually small but can be painful, as the tissue around the anus is supplied with lots of nerve endings. The tears can bleed bright red blood, which will show while washing or on the toilet paper but soon stops. After passing stools, they start to heal but can re-open the next time. They usually heal completely in a week or two, but only after the stool has softened.

How are anal fissures diagnosed?

Initially, the doctor will diagnose constipation from your child’s history. They may look at your child’s anus to see if any anal fissures are visible. Occasionally, the doctors may suggest your child has an examination under anesthetic, to check the anus more closely and confirm that it is otherwise normal.

How are anal fissures treated?

Treatment aims to reduce the constipation, so that stool is easier to pass and the tissues around the anus are less likely to tear. This may involve a change in diet to include higher fiber foods, medicines to soften the stool so it is less painful to pass, and laxatives to stimulate passing stool. As well as reducing constipation, there are various options for making the anal fissures less painful until they heal. A warm bath can soothe the area for a while, but it should be patted dry rather than rubbed. Creams or ointments can be soothing, but certain ones containing steroids or anesthetics should only be used for a few days at a time.

What happens next?

Children who have developed anal fissures once are likely to develop them again. The key to preventing anal fissures is to avoid becoming constipated. Try to make sure your child to has a balanced diet containing plenty of fiber and encourage them to drink plenty of fluids.

Exomphalos is a type of abdominal wall defect. It occurs when a child’s abdomen does not develop fully while in the womb. Early in all pregnancies, the intestine develops inside the umbilical cord and then usually moves inside the abdomen a few weeks later. In exomphalos, the intestines and sometimes other organs such as the liver, remain inside the umbilical cord but outside the abdomen.

What causes exomphalos?

We do not know what causes exomphalos. It affects two in every 5,000 children born each year. Exomphalos can be associated with other problems, but the doctors will examine your child closely to check if this is the case.

What are the signs and symptoms of exomphalos?

Exomphalos is immediately recognizable because the child’s intestines are outside the body and covered in a membrane. The size of the bulging membrane containing the intestines and other organs varies from a small protrusion to quite a large lump. There are two types of exompahlos: Exomphalos minor where the opening is less than 4cm and only containing the intestine, and Exomphalos major where the opening is greater than 4cm and/or with the liver inside the cord.

How is exomphalos diagnosed?

In many cases, exomphalos is visible on pre-natal ultrasound scanning, which is useful because it gives time for discussions and planning for when and where to give birth.

How is exomphalos treated?

Exomphalos is a serious condition so needs prompt treatment soon after birth. Depending on the size of the exomphalos, your child may need to have it repaired in one operation or in several stages. If the exomphalos is small and the child is stable, they may have an operation soon after admission to the hospital, where the surgeon replaces the contents back inside the abdomen and closes up the base of the umbilical cord. If the exomphalos is larger, contains the liver and/or your child needs to be stabilised, doctors may place a silo or pouch over the intestines, which is closed over a period of days to weeks, to allow your child to grow so that there is room inside the abdomen.

What does the operation involve?

If your child is having a one-stage repair under general anaesthetic, the surgeons will replace your child’s entire intestine into the abdominal space and close up the hole at the base of the umbilical cord. Sometimes, they may need to use a ‘patch’ of material if the hole is quite large. They will cover the area with a dressing to protect the wound while it heals. In a staged repair, there is too much intestine outside of the abdomen to put back without causing further damage or the space inside the abdomen is too tight. While your child is under general anaesthetic, the surgeon will make a mesh sac and put it over the intestine which keeps it contained and protected. This sac is then suspended above your child so that gravity gradually moves the intestines back inside the abdomen. It is tightened regularly until all the intestine is inside the abdomen, which usually takes a few days to a few weeks. Your child will then have an operation under general anaesthetic to close up the skin and muscles.

Are there any risks with the operation?

All surgery carries a small risk of bleeding during or after the operation. During the operation, the surgeon will minimise any bleeding by sealing off the blood vessels affected. There is a very small chance that nearby structures in the abdomen could be damaged during surgery but this is a very rare occurrence. Every anaesthetic carries a risk of complications, but this is very small. Your child’s anaesthetist is a very experienced doctor who is trained to deal with any complications. It can take a while after the operation for the intestine to start working properly so your child may need to be fed intravenously using total parenteral nutrition (TPN) for a while. Some babies with exomphalos have breathing problems which may require more support for a longer period. Are there any alternatives to the operation? In some scenarios, the child may be treated with particular chemicals / ointments in order to make the membrane covering the intestine hard. The surgery may hence be delayed by a few weeks. Ultimately, the condition needs to be treated to allow your child to grow and develop.

What happens after the operation?

Your baby will come back to recover either in the intensive care unit .All babies are closely monitored after the operation, and so your baby will be connected to monitors to check their breathing, heart rate and oxygen levels. If your child needs help with breathing, they will be connected to a ventilator. They will also be given pain relief through the intravenous infusion (drip).

What happens next?

The outlook for children born with exomphalos varies depending on the size of the defect and any other problems. Many children have grown up to live normal lives. Children who have had aexomphalos repair may develop hernias in the years after the operation. This is because the abdomen has fewer muscles than usual.

The intestines form early in pregnancy as a long straight tube. Before the tenth week of pregnancy, they develop into the separate organs making up the digestive system. Occasionally, the intestines are not completely connected or blocked (atresia). Sometimes there is a partial blockage (web) inside the intestine. Any part of the intestines can be affected by atresia or stenosis. Duodenal Atresia is one type. This occurs in around one in 6,000 births where the duodenum is closed off rather than being a tube. If the jejunum or ileum are affected, this is called ‘small bowel atresia’. Small bowel atresia is more common than duodenal atresia. We do not know how exactly how many babies are born with small bowel atresia each year but we do know that it affects boys and girls equally. It is more common in twins or multiple births and babies born prematurely or with low birthweight. Colonic atresia, affecting the large bowel, is very rare. Small bowel atresia affects two areas of the small bowel – the jejunum and the ileum. The jejunum is the section of small bowel after the duodenum and is where the majority of nutrients are absorbed. The ileum is the main part of the small bowel, making up over half of its entire length, and connects to the large bowel. The blockage can affect any part of the ileum or jejunum.

What causes small bowel atresia?

More research is needed into the causes of small bowel atresia but currently doctors think that it is caused by reduced blood supply to sections of the bowel as the baby is developing in the womb. It is unlikely that it is caused by anything you did or did not do during pregnancy.

What are the signs and symptoms of small bowel atresia?

Many babies born with small bowel atresia appear well at birth but when they start to feed, they start to have nausea and vomiting and their vomit may be green. Their abdomen may appear swollen but soft and their skin may develop a yellow tinge (jaundice). All newborn babies have meconium in their bowel. This is the dark green stool passed in the first day of life. Babies born with small bowel atresia may not pass any meconium at all or only a small amount. Not passing meconium does not prove that a baby has small bowel atresia but it may suggest it. Some babies with small bowel atresia pass meconium as expected.

How is small bowel atresia diagnosed?

When a baby with small bowel atresia is developing in the womb, they are may be surrounded by much more amniotic fluid than usual (polyhydramnios). Small bowel atresia can sometimes be suggested during pregnancy using an ultrasound scan. After the baby is born, small bowel atresia is usually diagnosed when there are signs of an obstruction, such as vomiting, green bile and a swollen abdomen. An x-ray scan may show a blockage. Occasionally, doctors may suggest using a contrast scan and/or enema instead or as well as an x-ray. Contrast scans and enemas use a thick, white liquid called barium or a clear liquid (contrast), both of which show up well on x-rays. The contrast cannot pass through the atresia suggests that atresia can be a cause.

How can small bowel atresia be treated?

Small bowel atresia is repaired in an operation under general anaesthetic. The operation to repair the atresia can is usually carried out using open surgery. Sometimes a laparoscopic surgery (key hole procedure) may help diagnose the problem so that it can be repaired using open surgery.

Are there any alternatives?

No. Small bowel atresia always requires surgical treatment to allow your baby to feed.

What happens before the operation?

Your baby will be transferred to the hospital soon after birth. If your child is dehydrated, they will need a ‘drip’ of fluids for a while before the operation. Your child will also need a nasogastric tube, which is passed up the nose, down the foodpipe and into the stomach. This will drain off the stomach and bowel contents and ‘vent’ any air that has built up, which will make your child more comfortable. When your child is stable, the surgeon will explain about the operation in more detail. Sometimes the atresia is suspected but may not be the only possible cause of the blockage. The surgeon will explain this to you.

What does the operation involve?

The surgeon will look at the bowel to determine the level of the blockage. If it is an atresia, this section is removed and the cut ends are joined together (anastomosis). This provides a clear passage for food and fluid to travel through your child’s intestine. The remainder of the small intestine will be checked for further atresias and treated if identified. If it is not possible or safe to join the two ends together during the same procedure, the surgeon may bring the end of the intestine to an artificial opening (stoma) in the abdomen to form an ileostomy.

Are there any risks?

All surgery carries a small risk of bleeding during or after the operation. There is a chance that the area where the two ends of bowel were joined could start to leak, allowing bowel contents to escape into the abdomen. This is usually treated with antibiotics, but a second operation may be needed to check the leaking portion. All abdominal surgery carries the risk of strictures forming. These are areas of scar tissue that can narrow the intestines, leading to obstruction. If your child vomits green bile and has a swollen abdomen, they should be reviewed urgently by a doctor. It can take a while after the operation for the bowel to start working properly so your child may need to be fed intravenously using total parenteral nutrition (TPN) for a while. This affects many children.

What happens after the operation?

While your child’s intestines recover and start to work, they may be fed through a tube into their veins (total parenteral nutrition or TPN). This will gradually be replaced by breast or bottled milk, given through the naso-gastric tube when your child is able to tolerate this. As your baby recovers, you will be able to feed them from the breast or bottle. Over time, the drips and monitors will be removed one by one.Most children stay in hospital for one to two weeks, but occasionally a longer stay is needed.

What happens next?

The outlook depends on the amount of damage to the bowel. Adhesions can form after any abdominal surgery and can cause further problems such as blockage or pain. This however is quite rare and may sometimes require another operation to separate the adhesions.


What is a bronchoscopy and why does my child need one?

A bronchoscopy is a procedure that allows the doctor to look inside your child’s airway (trachea and bronchi). During the procedure, the doctor may also take a biopsy (small sample of tissue) or wash out secretions. The secretions will be sent to the laboratory to look for infection. Bronchoscopy is also done to remove any foreign body or particle that your child has inadvertently inhaled and has stuck in his air passage.

Bronchoscopy is also done after an operation to the trachea, bronchi or lungs to check that they are healing well.

What does a bronchoscopy involve?

Your child will have the bronchoscopy under general anaesthetic. The doctor will pass a bronchoscope (a thin, tube with a bright light at the end) down into your child’s airway. He or she will then be able to examine the airways closely. Once the bronchoscopy has finished, the doctor will remove the bronchoscope and spray some local anaesthetic on the back of your child’s throat.

Impacted Peanut in the Bronchus seen at Bronchoscopy What happens afterwards?

Your child will wake up from the general anaesthetic in a separate recovery room. Some children wake up straightaway but others may sleep for another two hours or so.

About three hours after the procedure, once your child is awake and sitting up on his or her own, he or she will be able to eat and drink.

Exstrophy means ‘turned inside out’. Bladder exstrophy is a congenital (present at birth) abnormality of the bladder. It happens when the skin over the lower abdominal wall (bottom part of the abdomen) does not form properly, so the bladder is open and exposed on the outside of the abdomen. In epispadias, the urethra does not form properly. All boys with bladder exstrophy also have epispadias, but epispadias can also be isolated and occur on its own. In boys, the urethra may be very short and split, and as a result it emerges on the top surface of the penis rather than in its usual position at the end of the penis. The split may be small, or, when it occurs in boys born with bladder exstrophy, it may involve the full length of the penis, making the penis short and broad. In girls, the opening of the urethra is higher and wider than usual, the labia (the lip-like folds encircling the vaginal opening) are further apart than normal and the clitoris (a small, very sensitive part of the female genitalia) is split in two.

What features are associated with bladder exstrophy?

As well as the bladder being exposed, babies with bladder exstrophy may also have related problems affecting their urinary system and pelvic bones. These related problems vary in severity and do not affect every baby. These will be confirmed using ultrasound scans and x-rays, and may be corrected during a series of operations.


They include:
  • Problems with the neck of the bladder and sphincter (ring of muscle that squeezes and relaxes to let urine flow from the bladder)
  • The bladder has a smaller capacity than usual, so cannot hold much urine
  • The ureters join the bladder in a different place to normal
  • The middle part of the pelvic bones are separated

Bladder exstrophy can be associated with other problems, but the doctor will examine your child closely to see if this is the case. Some may need to be corrected with an operation, but others do not. The more common problems include:

  • The anus is further forward than usual
  • The umbilicus (belly button) is lower down than usual
  • Umbilical and Inguinal Hernia, where part of the abdominal lining and sometimes a section of intestine bulges out through a weak area in the abdominal wall muscles
  • Undescended testes, where the testicles are not in their usual place in the scrotum
How are bladder exstrophy and epispadias diagnosed?

Bladder exstrophy is sometimes diagnosed before birth using ultrasound scans. However, it is often not picked up before birth, but will be obvious once your baby is born. Epispadias in boys is usually identified at birth, but in girls the diagnosis is usually made later when they develop bladder control problems or infections.

What causes bladder exstrophy and epispadias?

We do not know why bladder exstrophy occurs. It affects the developing baby during very early stages of development, at about four to six weeks into the pregnancy. This is when organs, muscles and other tissues start to form. It is not the result of anything either parent did or did not do, and is not simply an inherited condition.

How common is bladder exstrophy?

Bladder exstrophy occurs in one in every 40,000 births, affecting two to three times more boys than girls. If you have a baby with bladder exstrophy the chance of having another baby with bladder exstrophy is increased to about one in 100.

How are bladder exstrophy and associated problems treated?

Bladder exstrophy and epispadias are corrected in a series of operations over the first few years of life. The overall aim of treatment is to prevent any kidney damage and correct the abnormalities so that your child’s urinary system and genitals work properly and look as normal as possible. The doctor will explain the treatment plan for your child; this can vary from child to child.

What do the operations involve? Bladder and abdominal wall repair operation – first few days after birth

This operation closes the bladder and abdominal wall, so that that the bladder is inside the body and in the correct position. After the operation, urine will drain from the bladder through a number of catheters (plastic tubes) placed in the bladder. You and your child will be able to go home once your child is recovering and has been reviewed by the doctors.

Bladder neck reconstruction procedure – at one to two years old

After the initial closure of the bladder exstrophy, there is no sphincter at the junction of the bladder and urethra. Surgery for bladder neck reconstruction uses existing muscle and soft tissue to create a ring of muscle that acts like a sphincter. This holds urine in the bladder allowing it to stretch and gain more capacity and also helps form a strong stream of urine when urinating. In boys, the bladder neck reconstruction procedure may also involve a reconstruction of the urethra and penis, or it may be done in a separate operation at a later stage. During the same operation, the ureters may be re-positioned within the bladder if they are not joining the bladder in the correct place. This can cause a condition called vesico-ureteric reflux (VUR) where the valves can fail, allowing urine to flow backwards from the bladder towards the kidney. The ureteric re-implantation operation involves disconnecting the ureters and re-attaching them in the correct place.

Are there any risks with these operations?

All surgery carries a small risk of bleeding during or after the operation. Every anaesthetic carries a risk of complications, but this is small. There is a small risk of infection, but your child may be given antibiotics as a precaution. After the first operation to repair the bladder and abdominal wall, there is a risk that the wound will not heal properly and open up again. This can cause the bladder to move out of position. This happens more often if the area to be repaired is large, as the skin needs to stretch to cover it. If the wound opens up again, your child will need another operation to repair the bladder and abdominal wall. The surgeons may correct the pelvic bones during this operation as well. There is also a risk of kidney damage in children with bladder exstrophy. The abnormal join between the ureters and bladder allows urine to flow backwards towards the kidneys. This is called vesicoureteric reflux (VUR). It can sometimes lead to a condition called hydronephrosis, where the kidneys become swollen. Both these conditions will be monitored closely throughout your child’s treatment.

What is the outlook for babies born with bladder exstrophy?

Children with bladder exstrophy repair need some further treatment later in childhood if they are having problems keeping dry. If the bladder does not develop well, they many need an operation called bladder augmentation, which involves making the bladder larger, and therefore able to hold a larger volume of urine, using a section of intestine. These children then empty their bladder using a catheter to drain away the urine. The catheter can be inserted either into the urethra or a specially made channel called a Mitrofanoff channel. The external genitalia of an individual born with bladder exstrophy or epispadias will always look different from others. In males the penis tends to be shorter and broader, but this does not usually cause any problems with their sex lives. Men born with bladder exstrophy have fathered children, although they may need fertility treatment. In many cases, sperm production is normal and sperm are healthy but ejaculating may be a problem. Women born with bladder exstrophy have also had children, although pregnancy should be supervised by a specialist obstretrician and their babies are usually delivered by caesarean section.

Outlook for babies born with bladder exstrophy – Indian Scenario ?

In India, there may be problems with regular follow up due to far away distances from the hospital and lack of nursing care around the area where the child lives. Also in the event of the parents not willing for multiple surgeries, an option for a permanent urinary diversion (ureterosigmoidostomy) may be offered where the tubes from the kidneys are joined into a part of the large intestine (sigmoid colon). This would help to keep the child dry and he would then be passing urine and stools from the anal opening. These are complex surgeries and are carried out only after detailed discussion and interaction between the parents, patient families and the doctors.


How does the urinary system work?

The urinary system consists of the kidneys, the bladder, the ureters and the urethra. The kidneys filter the blood to remove waste products and form urine. The urine flows from the kidneys, down through the ureters to the bladder. From here it passes through another tube called the urethra to the outside when urinating (urinating).

What is a cystoscopy and why does my child need one?

A cystoscopy is a test that allows the doctor to look inside and around your child’s bladder using an endoscope (a tube containing a small camera and a light). The cystoscopy is carried out under a general anaesthetic (your child will be asleep) and lasts less than an hour.

A cystoscopy allows the doctors to find out what is causing your child’s problems without performing a larger operation. Your child may need a cystoscopy to find out if the bladder is infected, why there is blood in his or her urine or why he or she has poor bladder control.

Are there any alternatives to a cystoscopy?

A cystoscopy can give your doctor a fuller picture of your child’s condition. The only real alternative is an operation to examine the inside of the bladder, but this is avoided wherever possible. A cystscopy is quicker and has fewer lasting effects than an operation.

What does the procedure involve?

Your child will have this procedure under a general anaesthetic. This means he or she will be asleep and not feel any pain during the test.

Once your child is asleep, the doctor will insert the endoscope into your child’s urethra. From here, he or she will pass it into your child’s bladder. The doctor can now look at the inside of your child’s bladder, and also the tubes leading from it to the kidneys. Before your child wakes up, we will give him or her some pain relieving medications. This will reduce any discomfort in the hours following the test.

What happens afterwards?

Your child will come back to the ward to recover and will be able to go home once he or she has had something to drink and urinated.

You should encourage, but not force, him or her to drink plenty of fluids. He or she may feel a stinging sensation when passing urine but this will pass in a day or two. Try to avoid giving your child fruit juice as this is acidic and makes the stinging worse. It does not matter if he or she does not feel like eating for the first couple of days. There may also be a small amount of blood in your child’s urine, but this is also temporary.

When you get home, you should give your child regular pain relief as often as he or she seems to need it.

What is a cleft lip repair?

Cleft lip repair is an operation to reconstruct the shape of the lip . If there is a cleft palate as well, then the front half (anterior) of the palate is also repaired. The earliest we do the operation is when babies are approximately three months of age. Babies are usually in hospital for about 3-4 days after the operation.

What does the operation involve?

The operation involves joining the tissues that have not joined before birth. The surgeon may use an operating microscope to allow the small structures to be accurately joined. The operation usually takes from one to two hours, depending on the extent of the cleft.

What anaesthetic is used?

Your baby is given a general anaesthetic by an anaesthetist who specializes in giving anaesthetics to babies and children.

Are there any risks?

There is a small risk of infection following the operation, but your baby will be given an antibiotic injection during the operation, and continue to take antibiotics afterwards in the form of medicine. Every anaesthetic carries a risk of complications, but this is very small.

Your baby’s mouth will be sore after the operations, partly due to the operation itself, but also because the surgeon will need to move it about to repair the lip. The nurses will give pain relief medicine, so that he or she is not uncomfortable, particularly when feeding.

When can my baby feed?

We are happy for your baby to feed as soon as he or she is awake after the anaesthetic. The first feed may be difficult, partly because the lip is numb from the operation.

What happens afterwards?

When your baby has returned to the ward, he or she may be offered fluids that may be taken more easily from a spoon or syringe. If your baby is reluctant to drink it may be necessary to give extra fluid through the drip. The drip will be removed once he or she is drinking well again. It is important to give your baby some cooled, boiled water to drink after each feed and medicine to keep the inside of the mouth clean.

Soon after the operation there may be some bleeding but this usually stops quickly. Only very rarely will any further measures be necessary to stop the bleeding. Your child’s lip may look swollen and bruised for the first few days after the operation, but this will soon go down.

A course of antibiotics will be prescribed to reduce the risk of infection. You will need to continue giving this antibiotic medicine for a few days after leaving hospital to complete the course.

When you get home…

By the time your child goes home he or she should be getting back to a normal feeding pattern. It is important to make sure your child is drinking enough. His or her lip may be swollen after the operation and the shape of his or her mouth may be different, but your child will soon adapt. You will be called to hospital for removal of the stitches on the 7th day following surgery.

A cleft palate is a defect or gap in the roof of the mouth. It can involve some or all of the part of the palate. A cleft palate can occur separately or together with a cleft lip.

What causes a cleft palate?

A cleft palate occurs during the first weeks of development in the womb. The palate is initially formed in two halves, lying either side of the tongue. Around the seventh or eight week the palate joins. This joining process may fail completely or stop at any point, resulting in a defect (cleft). In any unaffected family, the chance of cleft lip / palate is one in 700. If one parent or child has a cleft, the chance of cleft lip / palate in future children is one in 25 to one in 40. What are the signs and symptoms of cleft palate? The main symptoms are the effect the condition has on hearing, feeding and later speech. If a baby has an isolated cleft palate, they might have difficulty feeding properly because they can’t suck very well. The baby is unable to create a seal enabling them to create suction to get milk from the breast or bottle. Some special bottles are used to help babies with isolated cleft palates feed but difficulty with feeding can mean the baby gains weight more slowly than is meant to happen over the first few months. Other symptoms can include hearing problems as children with the condition are more at risk of glue ear. This can also lead to ear infections. As the palate plays an important role in speech it is important the cleft is repaired with surgery to reduce speech problems when the child is older. How is a cleft palate normally diagnosed? A cleft palate will be seen once a baby is born and is usually diagnosed at the time of the routine newborn baby check.

How is a cleft palate treated?

Treatment involves surgery. Most children require just one operation, but sometimes other operations may be needed to ensure the best possible speech outcome. An operation to repair a cleft palate usually takes place when a child is between nine and 12 months of age. The operation involves joining the tissues that have not joined before birth.

What happens next?

In the vast majority of cases, surgery is very successful. Most babies born with a cleft palate will lead totally normal lives. Children with a cleft palate will be monitored closely as they grow and develop. This will include their hearing and speech. Most children are able to develop good speech and language skills following surgery. But sometimes a repaired cleft palate can make it difficult for a child to pronounce some sounds clearly. This may affect speech quality making it sound a bit ‘nasal’. A speech and language therapist will be able to help. However, most children will be able to speak normally.

Cystic Hygroma: (Also read Lymphatic Malformations)

A cystic hygroma is a collection fluid-filled sacs known as cysts that result from a malformation in the lymphatic system. A cystic hygroma is also known as a lymphatic malformation. The lymphatic system is a network of vessels within the body which form part of the immune system. Lymph nodes are located in the neck, armpits and groin areas and filter the lymph fluid.

What does a cystic hygroma look like?

Cystic hygromas can develop anywhere in the body, but are commonly found in the neck and armpits. It appears as a painless soft lump, which may be translucent.

What causes a cystic hygroma and can it be prevented?

A cystic hygroma forms when the lymph vessels fail to form correctly during the first few weeks of pregnancy. It cannot be prevented as it occurs so early in pregnancy, usually before the pregnancy is confirmed. Nothing you did or did not do during pregnancy caused the cystic hygroma to develop. The exact cause of cystic hygromas is not clear. They occur in approximately one per cent of children and can affect children of any race and both boys and girls. How is it diagnosed? Cystic hygromas may be seen on scans during pregnancy. Many cystic hygromas are visible at birth or in early infancy, with almost all being diagnosed by the time a child is two years old. If the cystic hygroma is in a location where it may be interfering with other tissues and structures, scans such as ultrasound or magnetic resonance imaging (MRI) may be needed.

How can cystic hygroma be treated?

Sometimes cystic hygromas do not need to be treated. For babies, where the cystic hygroma is causing functional problems, the treatment options include surgical removal or injection sclerotherapy. Surgical removal Detailed scans will be needed to plan the operation, and it will only be carried out if the surgeon is confident that the operation will be beneficial. There will be an amount of scarring after the operation, as with all surgery. Sclerotherapy This is a procedure carried out by a doctor who specialises in interventional radiology, who injects a medicine into the cysts. The medicine mimics an infection, causing an inflammatory reaction, which makes the cystic hygroma shrink. It may take several sclerotherapy sessions for the cystic hygroma to be completely treated and even then, it might grow again. Both surgical removal and sclerotherapy are carried out while the child is under a general anaesthetic. The doctors will discuss with you the treatment options suitable for your child. Some children may need both treatments. Are there any risks with these treatment options? Every procedure carries some risk of infection and bleeding. Your child will be given an antibiotic injection during their operation to reduce the risk of infection. Every anaesthetic carries a risk, but this is very small. Modern anaesthetics are very safe and your child’s anaesthetist is a very experienced doctor who is trained to deal with any complications. With surgical removal and sclerotherapy, there is a small chance of damage to the structures surrounding the cystic hygroma. This is why detailed imaging scans are carried out before the operation. Even after the cystic hygroma has been removed or shrunk, there is a chance that it could return. Treatment can be repeated if needed.

What happens afterwards?

After the procedure, your child will return to the ward to wake up fully from the anaesthetic. The wound area will be covered with a dressing to protect it and a drain may be in place for the first few days then removed. When you get home • You should give your child pain relief medicines and a course of oral antibiotics. • Your child will need to come back to the hospital for a check up appointment one to two weeks after the operation.

What is the outlook for children with a cystic hygroma?

The outlook is generally good, although the size and location of the cystic hygroma can influence long term outcomes. As explained above, cystic hygromas can come back after treatment, which would require another operation or sclerotherapy procedure.

Choledochal Cysts in Children

A choledochal cyst is a rare congenital swelling of the hepatic or bile duct of the child’s liver.

  • This is the tract that transports bile produced by the cells to the gallbladder and duodenum (the first part of the small intestine).
  • These cysts can be intrahepatic, meaning that they occur in the part of the duct located inside of the liver.
  • They can also be extrahepatic, meaning part of the bile duct that is located outside the liver.
What does the liver do?

The liver is located in the upper right-hand portion of the child’s abdominal cavity, beneath the diaphragm and on top of the stomach, right kidney and intestines. The liver consists of two main lobes, both of which are made up of thousands of lobules.These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. The hepatic duct transports bile produced by the liver cells to the gallbladder and duodenum, which helps to break down fats, preparing them for further digestion and absorption. All of the blood leaving the stomach and intestines passes through the liver. The liver processes this blood and breaks down the nutrients and drugs in the blood into forms that are easier to use for the rest of the body.

What are the most common varieties of these cysts?

There are five basic types and they’re classified by where they appear.

  • Type 1 — A cystic dilation of the extrahepatic bililary duct. This is the most common type, making up about half of all choledochal cysts.
  • Type 2 — An abnormal pouch or sac opening from the duct.
  • Type 3 —A cyst located within the duodenal wall.
  • Type 4 — Swellings of both the intrahepatic and extrahepatic biliary tracts.
  • Type 5 —Multiple intrahepatic cysts. This type of clustering of cysts is also known as Caroli's disease and is the least common type.

How common are choledochal cysts?

  • Choledochal cysts occur in between 1 and 100,000 and 1 in 150,000 people in Western countries but is much more common in Japan.
  • They are three to eight times more common in females than males.
What causes choledochal cysts?

The cause of these cysts is unknown, but researchers believe that their formation is due to an abnormal connection between the pancreatic and hepatic ducts. This abnormal connection leads to a reflux of pancreatic juice into the biliary tract, which could be responsible for cyst formation.

What are the symptoms of choledochal cysts?

The following symptoms are usually experienced by an older child whose earlier diagnosis of this congenital anomaly may have been missed.

  • Abdominal pain in the right upper quadrant
  • Jaundice
  • Abdominal Mass
  • Nausea
  • Fever
  • Pancreatitis
How are choledochal cysts diagnosed?

Choledochal cysts can be diagnosed prenatally (before birth) on an ultrasound. After your baby is born, you or your child's doctor may notice a right upper quadrant mass, with or without jaundice. Your child will likely undergo a combination of the following tests to verify the diagnosis: Computerized tomography scan (CT or CAT scan): A CT scan shows detailed images of any part of your child’s biliary system. Magnetic Resonance Cholangiopancreatography (MRCP): Magnetic resonance cholangiopancreatography (MRCP) is a special type of magnetic resonance imaging (MRI) exam that produces detailed images of the hepatobiliary and pancreatic systems, including the liver, gallbladder, bile ducts, pancreas and pancreatic duct.

What is the treatment for choledochal cysts?

Surgery is the only feasible treatment for choledochal cyst. This involves removal of the choledochal cyst, followed by duct reconstruction using a piece of intestine. A number of possible approaches exist, depending on cyst location etc... Sometimes, the appendix is also used as a conduit for reconstruction of the biliary tree. Surgery showing the gall bladder, choledochal cyst The right and left hepatic ducts seen after removal of the choledochal cyst Without surgery, there is an ongoing risk of other problems:

  • Biliary obstruction and stone formation
  • Infection of the ducts
  • Jaundice
  • Cirrhosis
  • Perforation of the cyst
Another long-term concern is for malignant degeneration. Choledochal cysts are inflammatory in nature, which makes them at risk for becoming cancerous if left untreated. Outcome for children with choledochal cysts after surgery Children can lead a normal life after surgery for choledochal cysts. There are no issues related to digestion or their growing up. We normally follow then up after surgery with ultrasound scan after 6 months. If required blood tests are also carried out on follow up.

What is duodenal atresia?

Duodenal atresia means the duodenum (first part of the small intestine just beyond the stomach) is closed off rather than being a tube. This stops food and fluid passing from the stomach into the intestines.

How is it diagnosed?

Duodenal atresia can sometimes be discovered during pregnancy as it often shows up on antenatal ultrasound scanning. Some babies with this condition are born prematurely. Many babies appear well at birth but when they start to feed, they are sick and their vomit is green. An X-ray scan can confirm this diagnosis. Duodenal atresia is a rare condition and occurs in about one in 10,000 births. It can be associated with other problems, so the doctors will examine your child closely to check if this is the case. One third of all children with duodenal atresia have Downs’ syndrome.

How is it treated?

Duodenal atresia is repaired in an operation under general anaesthetic (so your baby is deeply asleep), which lasts around 1 – ½ hours.

Are there any alternatives?

No. Duodenal atresia always requires treatment to allow your baby to feed.

What happens before the operation?

Your baby will need admission in hospital. To begin with, your child will be nursed in a warner and will have a naso-gastric (NG) tube passed through his or her nose into the stomach. This will drain off the contents of the stomach and stop your child from vomiting. It also releases any excess air from the stomach, which could make your child uncomfortable. He or she will also have an intravenous infusion (drip) of fluids and medicines.

What does the operation involve?

The surgeon will cut the blind end of the duodenum and connect it to the rest of the intestine. This provides a clear passage for food and fluid to travel from your child’s stomach to his or her intestine.

What happens afterwards?

Your baby will return to the ward to recover. All babies are closely monitored after the operation, and so your baby will be connected to monitors to check his or her breathing, heart rate and oxygen levels. He or she will also be given pain relief through the intravenous infusion (drip).

While your child’s intestines recover and start to work, he or she will be fed through a tube into his or her veins. This will gradually be replaced by breast or bottled milk, given through the naso-gastric tube when your child is able to tolerate this. As your baby recovers, you will be able to feed him or her from the breast or bottle. You will be able to go home once your baby is feeding properly and gaining weight.

What is a diaphragmatic hernia?

The diaphragm is a curved muscle that separates the contents of the chest from the abdomen (tummy). Diaphragmatic hernias occur when the diaphragm does not form completely, leaving a hole. The hole can be on either side, but in most children it is on the left side. This allows part of the intestine (gut) to develop in the chest, which can compress the lungs and can stop them developing properly before birth.

We do not know exactly what causes diaphragmatic hernias. It is not due to anything that happens during pregnancy. They are very rare, occurring in between one in 2,500 and one in 5,000 pregnancies. They are more common in boys than girls. Diaphragmatic hernias can be associated with other problems, so the doctors will examine your child closely to check if this is the case.

How is a diaphragmatic hernia repaired?

Diaphragmatic hernias are repaired in an operation under general anaesthetic which can last between one to two hours.

Are there any alternatives?

Not really, no. Diaphragmatic hernias inevitably require treatment, because if they are not repaired your baby’s breathing problems would get worse as he or she grew. Feeding problems would also get worse with time.

What does the operation involve?

During the operation, the surgeon will move your child’s intestine back into the abdomen and repair the hole in their diaphragmIf your child’s intestine has become twisted while it is in the chest (which is not uncommon), the surgeon will correct this during the same operation.

What happens afterwards?

Your baby will come back to the intensive care unit to recover. Babies may need ventillatory support after surgery. There may be a tube from the operation site (chest drain) to drain off air and fluid so that the lungs have room to expand. This will be removed as soon as it is no longer needed. The child will start to feed once the intestines recover and start to work. As your baby recovers, you will be able to feed him or her from the breast or bottle.

Your child’s lungs may not have developed properly by being compressed by the intestines in the chest. The length of time that your baby needs the ventilator depends on the condition of their lungs.

What is the outlook for children with diaphragmatic hernias?

This depends on how quickly the condition is diagnosed and how much the lungs were damaged before birth. The outlook is improving all the time, as better treatment is developed. Children who would previously have not survived are now growing up and we will only know the long-term effects of diaphragmatic hernia by studying these children closely.

Some children who have had a diaphragmatic hernia develop a problem with gastro-oesophageal reflux when they are older. This is where the contents of the stomach flow back up the oesophagus (gullet) causing pain and irritation. Further information regarding the same will be given to you by your doctor.


Exomphalos is a type of abdominal wall defect. It occurs when a child’s abdomen does not develop fully while in the womb. Early in all pregnancies, the intestine develops inside the umbilical cord and then usually moves inside the abdomen a few weeks later. In exomphalos, the intestines and sometimes other organs such as the liver, remain inside the umbilical cord but outside the abdomen.

What causes exomphalos?

We do not know what causes exomphalos. It affects two in every 5,000 children born each year. Exomphalos can be associated with other problems, but the doctors will examine your child closely to check if this is the case.

What are the signs and symptoms of exomphalos?

Exomphalos is immediately recognizable because the child’s intestines are outside the body and covered in a membrane. The size of the bulging membrane containing the intestines and other organs varies from a small protrusion to quite a large lump. There are two types of exompahlos: Exomphalos minor where the opening is less than 4cm and only containing the intestine, and Exomphalos major where the opening is greater than 4cm and/or with the liver inside the cord.

How is exomphalos diagnosed?

In many cases, exomphalos is visible on pre-natal ultrasound scanning, which is useful because it gives time for discussions and planning for when and where to give birth.

How is exomphalos treated?

Exomphalos is a serious condition so needs prompt treatment soon after birth. Depending on the size of the exomphalos, your child may need to have it repaired in one operation or in several stages. If the exomphalos is small and the child is stable, they may have an operation soon after admission to the hospital, where the surgeon replaces the contents back inside the abdomen and closes up the base of the umbilical cord. If the exomphalos is larger, contains the liver and/or your child needs to be stabilised, doctors may place a silo or pouch over the intestines, which is closed over a period of days to weeks, to allow your child to grow so that there is room inside the abdomen.

What does the operation involve?

If your child is having a one-stage repair under general anaesthetic, the surgeons will replace your child’s entire intestine into the abdominal space and close up the hole at the base of the umbilical cord. Sometimes, they may need to use a ‘patch’ of material if the hole is quite large. They will cover the area with a dressing to protect the wound while it heals. In a staged repair, there is too much intestine outside of the abdomen to put back without causing further damage or the space inside the abdomen is too tight. While your child is under general anaesthetic, the surgeon will make a mesh sac and put it over the intestine which keeps it contained and protected. This sac is then suspended above your child so that gravity gradually moves the intestines back inside the abdomen. It is tightened regularly until all the intestine is inside the abdomen, which usually takes a few days to a few weeks. Your child will then have an operation under general anaesthetic to close up the skin and muscles.

Are there any risks with the operation?

All surgery carries a small risk of bleeding during or after the operation. During the operation, the surgeon will minimise any bleeding by sealing off the blood vessels affected. There is a very small chance that nearby structures in the abdomen could be damaged during surgery but this is a very rare occurrence. Every anaesthetic carries a risk of complications, but this is very small. Your child’s anaesthetist is a very experienced doctor who is trained to deal with any complications. It can take a while after the operation for the intestine to start working properly so your child may need to be fed intravenously using total parenteral nutrition (TPN) for a while. Some babies with exomphalos have breathing problems which may require more support for a longer period.

Are there any alternatives to the operation?

In some scenarios, the child may be treated with particular chemicals / ointments in order to make the membrane covering the intestine hard. The surgery may hence be delayed by a few weeks. Ultimately, the condition needs to be treated to allow your child to grow and develop.

What happens after the operation?

Your baby will come back to recover either in the intensive care unit .All babies are closely monitored after the operation, and so your baby will be connected to monitors to check their breathing, heart rate and oxygen levels. If your child needs help with breathing, they will be connected to a ventilator. They will also be given pain relief through the intravenous infusion (drip).

What happens next?

The outlook for children born with exomphalos varies depending on the size of the defect and any other problems. Many children have grown up to live normal lives. Children who have had aexomphalos repair may develop hernias in the years after the operation. This is because the abdomen has fewer muscles than usual.

Empyema is a condition where pus collects in the pleural space (space outside the lung and inside the chest wall), often as a complication of pneumonia. The lungs and inside of the chest cavity have a smooth covering called the pleura that lets the lungs expand without rubbing on the inside of the chest. The two layers of pleura are usually in close contact with only a small space in between (pleural space) filled with a small amount of pleural fluid acting as lubrication. This complication of pneumonia usually occurs in three stages. Initially, clear fluid collects up in the pleural space which can then become infected. The fluid thickens and can affect the pleura, causing sections to ‘stick together’ eventually forming ’pockets’– this is called empyema. The infected fluid stops the lungs inflating completely, causing increasing breathing difficulties.

What causes empyema?

Empyema usually develops following pneumonia – various bacteria can cause pneumonia (most common ones are Staphylococcus pneumoniae and Staphylococcus aureus). Empyema seems to becoming more common, particularly in young children aged one to four years. It tends to occur during winter and spring season, when pneumonia and other chest infections are more common. Sometimes tuberculosis may also be a cause of empyema.

What are the signs and symptoms of empyema?

Empyema is usually suspected when a severe bout of pneumonia does not improve with treatment. Children usually show symptoms of being generally unwell with a high temperature. They may find breathing harder than normal, struggling to catch a breath. Their heart rate may also be higher than usual. Some children may describe pain in their chest when breathing.

How is empyema diagnosed?

If empyema is suspected, a chest x-ray may be the first test suggested to confirm or rule out the diagnosis. Chest x-rays will show white areas that suggest fluid. An ultrasound of the chest is more precise at showing the amount of fluid and the exact location and whether there are any pockets. In some cases, the doctor may also ask for a CT Scan of the chest to make sure that the child does not have any structural problems with the lung like a lung abscess which may have caused an empyema.

How is empyema treated?

Empyema previously used to be treated by placing a chest drain in the chest and with intravenous antibiotics as well as medicines to stop the pus clumping together. However, nowadays with the advance of minimally invasive surgery, Empyema is treated with VATS (Video assisted thoracoscopic surgery) wherein a telescope is inserted into the chest cavity and all the pus is removed under vision. The pus pockets are broken down and washed with antiseptic liquids and a chest drain is placed. The surgery is completed with 2 or 3 5 mm instruments rather than placing a big cut on the chest. Also as the procedure is done undervision, the doctor is sure that the pus has been completely cleared and the child also recovers early.

What happens next?

The outlook for children with empyema is usually good once it has been diagnosed and treated promptly. Long term lung damage is rare. With thoracoscopy, the recovery is just in a few days. Once the lung is completely expanded as seen on follow up x-ray, the chest tube is removed and the child is sent home on oral medications. They will also need regular follow up clinic appointments, usually involving a chest x-ray, to check that the pleura is healing properly without any problems.

Nose bleeds are when the small fragile blood vessels in the nose break. This will cause the nose to bleed. It is a common condition, especially in young children. Children who have frequent nosebleeds should be checked for underlying conditions by a doctor.

What causes nose bleeds?

Nosebleeds are pretty common, especially in young children. This is because the blood vessels in the nasal lining are close to the surface and quite fragile. They can rupture easily. A bump or bang on the nose can often result in a nosebleed. Young children often play very physical games, whether it’s rushing around on the playground at nursery or school or tumbling about at home. Bumps on the nose can be pretty common. If a child picks their nose or blows it too vigorously, this can also start a nosebleed. Sometimes even a violent sneeze can damage the nasal blood vessels, and trigger a nose bleed. While nosebleeds are rarely dangerous, very occasionally, a nosebleed can indicate a more serious underlying problem like a head injury.

What are the signs and symptoms of nose bleeds?

If a child has a nosebleed after suffering from a bump on the head, it’s important to look carefully for other signs that might indicate an underlying injury. If the child has any of the following symptoms emergency medical advice should be sought: • confusion • drowsiness • nausea and vomiting • losing fluid through their nose that is thin and watery

How are nose bleeds treated?

If a child has a nose bleed, the recommended course of action is: • Ask the child to sit down with their head tilted forward. • Get them to breathe through their mouth. • Put a bowl under the nose and give them tissues or a cloth. • Ask them to pinch the front, soft part of their nose for 10 minutes – or pinch it for them if it is a young child. • If tolerated, apply an ice pack to the affected area • After 10 minutes, release the pressure – if the bleeding has not stopped, reapply the pressure for up to two further periods of 10 minutes. • Once the bleeding stops gently clean the area. Do not tilt the child’s head backwards. This will not stop the bleeding and can cause blood to trickle down their throat. This can make them vomit or choke and affect their ability to breathe.

When to ask for medical help about nose bleeds ?

If the bleeding does not stop after 30 minutes, it’s best to take the child down to your local hospital or seek medical advise. Frequent nosebleeds Some children do seem more prone than others to frequent nosebleeds. If a child does seem to suffer from them more than twice a week, it’s advisable to see a doctor. It’s important in the first instance to rule out an underlying bleeding disorder.The doctor may recommend blood tests. Another more common explanation for frequent nosebleeds is that the child may have picked their nose causing blood vessels in the septum, the cartilage which divides the nostrils, to bleed. The doctor can also check for any signs of infection. If there is any infection, the doctor will probably prescribe a course of ointment with antibiotic and anti-inflammatory properties. A child who has a deviated septum is more likely to suffer from nosebleeds. A deviated septum means that the septum is slightly bent, usually as a result of injury (for instance a sports injury or an injury sustained during birth). The deviated septum causes abnormal airflow through the nose which causes the lining of the septum to dry out and bleed easily.

What happens next?

Most children, even those who suffer from frequent nosebleeds, tend to outgrow it. Nosebleeds can also happen in adult life but it is less common.


There are a number of conditions that can affect the foreskin (the piece of skin covering the top of the penis). They can affect boys of all ages and are usually easily treated. The foreskin is the piece of skin that covers the top of the penis.

Conditions that can affect the foreskin include:

• Tight foreskin (Phimosis) – where the foreskin cannot be pulled back to reveal the head of the penis. All boys are born with phimosis. The foreskin retracts spontaneously by the age of 1 ½ to 2 years. A tight foreskin in puberty or adulthood can increase the risk of infection and cause problems with urination. • Paraphimosis – A condition where the foreskin has retracted but gets trapped, restricting blood flow to the head of the penis. The penis will turn dark purple. Paraphimosis requires immediate medical attention as this condition can cause permanent damage to the penis if not treated early. • Balanitis – an inflammation of the tip of the penis and foreskin usually caused by chemical irritation, bacterial or fungal infection. The head of the penis will become red, swollen and sore and there may be a thick and lumpy discharge.

What causes foreskin problems?

Foreskin problems can be the result of: • Poor personal hygiene (not cleaning the head of the penis correctly) • Infection • Forcible attempts to retract the foreskin What are the signs and symptoms of foreskin problems? The appearance of the foreskin is usually enough to see whether there is a problem.

How are foreskin problems diagnosed?

In the case of paraphimosis (where blood flow is restricted and the penis turns purple), you should visit the hospital immediately as this condition can cause permanent damage to the penis.

How are foreskin problems usually treated?

In the case of infection, a child may be given a course of antibiotics or a steroid cream to reduce inflammation and irritation. The course of treatment may last between two and four weeks, depending on the severity of the strain of infection. Some children may require a surgical procedure, such as: • Circumcision - where the foreskin is removed altogether. • Preputialplasty - where the opening of the penis is widened by an incision without removing the foreskin. The foreskin at the end of the operation would look just like a normal skin. All of these procedures are carried out under anesthetic

Can foreskin problems be prevented?

Good hygiene is key to preventing problems that can be caused by infection. In babies and children, the best way to clean the penis is by using water and baby soap. Don’t worry that you are not able to pull back the foreskin at this age – it’s very important not to try to retract a child’s foreskin forcibly, because this may cause damage to the delicate tissues of the penis. It could lead to bleeding, inflammation and the formation of scar tissue. Once the foreskin begins to retract, the glans will naturally become more visible and easier to clean. It is important to be gentle – the less scrubbing the better. When boys reach adolescence, they should be encouraged to retract and clean their foreskin regularly.

What happens next?

Once treated, a child should not experience any further discomfort and there should be no further impact on his health.


What is gastro-oesophageal reflux?

Normally, when we swallow food and drink, it moves down the foodpipe (oesophagus) to the stomach, where it starts to be broken down by the acids released from the stomach wall. After it has been partially broken down, it passes through to the small and large intestines, where all the goodness and excess water is removed.

When a baby or child has gastrooesophageal reflux, the food and drink travels down the foodpipe as normal, but some of the mixture of food, drink and acid travels back up the foodpipe, instead of passing through to the large and small intestines. As the food and drink is mixed with acid from the stomach, it can irritate the lining of the foodpipe, making it sore. This is gastro-oesophageal reflux disease. Some children also breathe some of the mixture into the windpipe (aspiration), which can irritate the lungs and cause chest infections.

In some children, the symptoms associated with gastro-oesophageal reflux disease disappear with or without treatment, usually by the age of two. However, in some children, gastro-oesophageal reflux disease is more of a long-term condition and can have a serious effect on both the child and family’s quality of life. The options for treating gastro-oesophageal reflux disease are improving all the time, with new medicines and surgical options being discovered.

Remember, not all children with gastroesophageal reflux need surgery.

What is Fundoplication?

A fundoplication is an operation used to treat gastro-oesophageal reflux. It uses the top of the stomach to strengthen the sphincter so it is less likely to allow food, drink or acid to travel back into the foodpipe.

What does the operation involve?

Many a times, this surgery can also be done with the help of laparoscopy or key hole surgery. There is a chance that keyhole surgery will not be possible for your child. Sometimes the surgeon will not be able to carry out an operation using the keyhole method for technical reasons, or because of unexpected findings. If this is the case, the surgeon will carry out the operation using a larger incision (cut) instead. Details regarding the same will be explained to you by your doctor.

Are there any risks?

Every anaesthetic carries a risk of complications but this is very small. Any surgery carries a small risk of infection or bleeding.

What happens afterwards?

Your child will be monitored closely for the first couple of days. After keyhole surgery, some older children may complain of shoulder pain and some crackling under the skin, caused by the carbon dioxide escaping into the tissue just under the skin; this does not usually last long and gradually improves over a day or two.

Your child will be able to drink when drainage from the naso-gastric tube or gastrostomy has slowed down and the fluid draining away is clear. As he or she gets used to drinking, small amounts of soft food can be added until your child is eating and drinking normally again. It may take up to 7 – 10 days for your child’s eating and drinking to get back to how it was before the operation.

Once your child is eating and drinking as normal and has recovered well from the operation, he or she will be able to go home. Most children stay in hospital for about five to seven days after this operation.

Are there any long-term effects of the operation?

Although the Nissen’s fundoplication operation is very successful at improving a baby’s gastro-oesophageal reflux disease and the symptoms associated with it, a quarter of all patients develop some long term effects afterwards, some of which we are able to treat.

Changes in feeding pattern - The operation makes the stomach slightly smaller. For some children this can mean that they may need to have smaller volumes of feed given more regularly.

Burping and vomiting - After the Nissen’s fundoplication operation, some children are unable to burp or vomit. In some this is temporary, but in many this is permanent.

Gas bloat - This is the name given to wind trapped in the stomach. It can usually be corrected by giving your child smaller feeds more frequently, rather than a few large feeds each day.

Dumping syndrome - This is a combination of things including nausea, retching, sweating, diarrhoea. It is caused by food travelling through the stomach at a much faster rate than usual so none of the goodness in the feed is absorbed. This can also be corrected by giving your child smaller feeds more frequently. These symptoms can take up to six weeks to settle.


What is hypospadias and what causes it?

Hypospadias is a birth defect affecting a boy’s penis.

It is a combination of three separate problems:

  • The hole through which urine passes (meatus) is not at the tip of the penis
  • The foreskin is gathered at the back of the penis with none at the front
  • The penis may be bent when stiff.

The position of the meatus varies; in some boys, the hole is only a small distance away from the tip of the penis, whereas in others, it is at the base of the penis, in the scrotum or behind the scrotum.

A

bout one in every 300 boys has hypospadias, although this figure seems to be rising. We do not know what causes hypospadias; more research is needed to learn more about the causes. It is unlikely to have been caused by anything that happened during pregnancy. Hypospadias can be associated with other conditions, such as inguinal hernia or undescended testicles, and your doctor will check your child to confirm or rule out any other problems.

Hypospadias How is hypospadias diagnosed?

Hypospadias is usually diagnosed by clinical evaluation of the appearance of the penis as early as at birth. Most boys need consultation when a few months’ old, so that treatment can be planned for when the child is about a year old. It is important that circumcision does not take place, as the foreskin is needed during the operation.

How is hypospadias treated?

Although hypospadias does not cause any immediate problems and is not life threatening. If hypospadias is left untreated it may not be possible for the child to pass urine standing up as the urinary stream may go on to wet his trousers or legs. Later on in life, having an adequate erection and having sex may be difficult. The aim of the operation is to straighten the penis, move the meatus to the tip of the penis and to remove the excess foreskin. By doing this, the penis will also look more normal. Usually, it is possible to make these corrections in one operation, but if the hypospadias is severe, correction may be needed in two or three stages in separate operations.

What does the operation involve?

The operation is carried out under an anaesthetic and lasts between one and two hours, depending on the severity of the hypospadias. The skin of the penis is used to create a tube, which extends the length of the urethra so that a new hole can be created at the tip of the penis.

Are there any risks?

There is also a small risk of infection, but your child may be given antibiotics as a precaution. After an anaesthetic some children may feel sick and vomit. They may have a headache, sore throat or feel dizzy. These side effects are usually short-lived and not severe

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For about one in ten boys, the original hole opens up again, so that your son passes urine through two holes. This can happen at any point after the operation. Small holes or fistula heal on their own over a course of 4 – 6 months. It will need to be fixed if it does not heal on its own by an operation. Occasionally, the new hole at the tip of the penis becomes small and your son may need follow up and dilatation to keep it of an adequate size.

What happens after the operation?

After the child comes back from operation theatre, he will be able to eat and drink once it wakes up and feels like it. When he comes back from the operating theatre, there will be a thin, tube (catheter) draining urine from your child’s bladder and a large dressing covering the penis; these will both need to stay in place for one week. The drainage tube can irritate the inside of the bladder, causing ‘bladder spasm’, but we will give your child some medicine to reduce this as well as pain relief medicine.

The dressing and drainage tube will need to stay in place for one week. As there is a small risk of infection, your child is likely to need a course of antibiotics for a week after the operation The dressing and tube will be removed a week after surgery. When the dressing has been removed, the penis will look red and swollen; this is normal and it will settle down within a few days.

Your son will be called for follow up a week to 10 days after surgery. If need be, the new tube will be examined with a dilator. This is a short procedure and your son will be ready to go home in about 3-4 hours.

How does the urinary system work?

The urinary system consists of the kidneys, the bladder and ureters. The kidneys filter the blood to remove waste products and form urine. The urine flows from the kidneys down through the ureters to the bladder. From here it passes through another tube called the urethra to the outside when urinating.

The ureters tunnel through the wall of the bladder at an angle to form a flap that acts as a valve. There is also a ring of muscle (sphincter) at the junction of the bladder and the urethra that stops urine leaking out in between episodes of urination. When passing urine, the muscles of the bladder wall squeeze the urine out of the bladder, at the same time as the muscles in the sphincter need to relax to let the urine flow down the urethra.

The valves between the ureters and the bladder prevent urine flowing backwards into the ureters, so that all the urine in the bladder is passed in one go, as the urine cannot travel anywhere else. As the urine leaves the bladder at a high pressure, the valves stop this high pressure being passed on to the kidneys.

What is hydronephrosis?

Hydronephrosis is a condition that can occur in the womb, where a baby’s kidneys fill up with urine and become larger. This can happen for various reasons. Hydronephrosis can also occur in adults, but the cause and treatment modalities are different from that of a child.

What are the symptoms of hydronephrosis?

Even if hydronephrosis is diagnosed before birth, this should not cause any symptoms in the mother and should not alter her antenatal care, other than possibly having a few more scans. Hydronephrosis does not usually cause a baby any problems before birth, but he or she may need close monitoring and assessment after birth to discover what is causing the hydronephrosis and keep an eye on the condition.

How is hydronephrosis diagnosed?

It is often diagnosed before a baby is born, as the enlarged kidneys can be seen on an ultrasound scan. Hydronephrosis can also be diagnosed after the baby is born using ultrasound scans.

What causes hydronephrosis? There are many causes of hydronephrosis, including:

A blockage, which can occur between the kidney and the ureter (pelviureteric junction or PUJ), between the bladder and the ureter (vesicoureteric junction or VUJ) or in the urethra (posterior urethral valve).

How common is the condition?

About 1 in every 300 people has one kidney affected by hydronephrosis. About 1 in every 600 people have both kidneys affected by hydronephrosis.

How can hydronephrosis be treated?

If the hydronephrosis is diagnosed during pregnancy, early treatment will consist of monitoring with ultrasound, to check that the baby is growing normally and the kidneys are not getting too large. The baby will usually be born by a routine delivery.

After the baby is born, the hydronephrosis will be monitored using ultrasound scans and other tests. The overall treatment for hydronephrosis depends on what is causing it:

  • If the cause is VUR, the child will probably be treated using antibiotics. Details can be obtained on the information on vesicoureteric reflux.
  • If the cause is a blockage, the treatment will depend on the degree of the blockage, the effect it is causing on the functioning of the kidneys or symptoms it is producing i.e. pain, urinary tract infections etc. In severe cases surgery may be necessary to clear the blockage. Many children with mild or moderate degrees of obstruction, regular follow up with close monitoring may be necessary. The decision of treatment however varies from child to child. Operation done for hydronephrosis to clear the blockage between the kidney and ureter is called a ‘pyeloplasty’.
What is the future for children with hydronephrosis?

If the cause of the hydronephrosis is an obstruction and this is removed, your child’s kidneys will be able to work properly. If the cause of the hydronephrosis is VUR that is not too severe, your child’s kidneys are also likely to work properly. If the cause of the hydronephrosis is severe VUR, the outlook may be less good. Your child may need an operation to correct the reflux and his or her kidneys may be damaged. However, the earlier the hydronephrosis is discovered, the better the outcome for your child.

What is a pyeloplasty and why is it needed? A pyeloplasty is an operation to remove a blockage in one of the ureters.

The blockage in one of the ureters is stopping urine flowing easily from the kidney into the bladder. The blockage is usually present from birth, but occasionally may appear later. If the ureter remains blocked, the kidney could become swollen and damaged. Sometimes, the blockage is caused by blood vessels getting in the way of the ureter. In this case, they will be moved and secured away from the ureter during the operation, but not removed.

What does the operation involve?

The operation involves locating the blockage in the ureter, remove the affected section and joining the cut ends of the ureter again. Details regarding the same will be explained in further details by the doctor.

What is hydrocephalus?

Hydrocephalus occurs when either too much cerebrospinal fluid (CSF) is produced (very rare) or when it is stopped from circulating or being re-absorbed. The CSF builds up within the ventricles (cavities) of the brain resulting in increased pressure on the brain. In babies, this also causes the head to enlarge.

CSF is a watery liquid that surrounds the brain and spinal cord, acting as a ‘cushion’. It also supplies nutrients to the brain.

What causes hydrocephalus? The most common causes are:
  • Congenital – This means that your child was born with hydrocephalus. Children born with spina bifida often develop hydrocephalus. This does not mean that all children with hydrocephalus also have spina bifida.
  • Prematurity – Hydrocephalus can occur as a complication of being born too early, and when there has been bleeding in the brain.
  • Meningitis – Hydrocephalus can occur as a complication of meningitis as the infection may cause a problem with reabsorption of CSF.
  • As a complication from a brain tumour – this does not mean children with hydrocephalus develop brain tumours.
  • Unknown – In many cases, we do not know what caused the hydrocephalus.
How is hydrocephalus diagnosed?

It is usually diagnosed by an increasing head circumference in infants, an ultrasound scan, a CT scan or sometimes an MRI scan.

How is hydrocephalus treated?

If hydrocephalus is not treated, your child’s head would get larger and the pressure on the brain would interfere with his or her development. In severe cases, this can result in permanent brain damage or visual problems. The aim of treatment is to reduce the pressure on the brain by draining the CSF away.

The fluid is drained away using a ‘shunt’, which is a long tube made of silicone. It is inserted in to the ventricles in an operation and drains the CSF away to the abdomen. The shunt contains a valve so that the fluid can only drain away from the head at the desired rate.

The operation

Part of your child’s hair, behind the ear, will be shaved and he or she will have an incision (cut) there in a horseshoe shape and a small incision on his or her abdomen.

Your child will have this operation under a general anaesthetic. The operation takes about 45 min to an hour. At the time of surgery fluid that is drained from the brain will be sent to the laboratory for examination.

What happens after the operation?

Close observation will be needed following surgery. Most children are able to take oral feeds the same evening of the operation. The usual stay in hospital is four to six days.

To begin with, the area around the top of the shunt may be slightly raised, but as the swelling settles and your child’s hair grows back you will not notice this. As your child grows, the area will become less prominent.

Going home

Your child may have dissolvable stitches or they may have stitches that need to be removed seven days after the operation.

Complications of a shunt

There can be complications to having a shunt inserted, of which you should be aware. The most common could be either an infection or a blocked shunt.

Symptoms of Infection The symptoms of an infection in the shunt may include:
  • Headache
  • Irritability
  • High temperature (over 37°C)
  • Not feeding well
  • Possibly vomiting
  • Possibly drowsy

Symptoms of a blocked shunt

In babies:
  • A bulging fontanelle (soft part of the top of the head)
  • Vomiting
  • Crying and irritability
  • Becoming sleepy (less responsive)
  • Looking pale
  • Increased head size
  • In toddlers and children:

  • Headache
  • Vomiting
  • Tiredness
  • Drowsy
  • Looking pale
What is a hydrocele and what causes them?

A hydrocele is a very common condition affecting boys, where a fluid filled sac develops inside the scrotum, making it look swollen. It is not painful and feels like a balloon filled with water. One or both sides of the scrotum can be affected.

While your child was developing in the womb, the testicles were developing inside the abdomen. Towards the end of pregnancy, the testicle travel through a passage into the scrotum. A hydrocele can develop when this passage fails to close, allowing fluid from the abdomen to flow through it to the scrotum. This causes the fluid-filled sac to develop.

Can a hydrocele be prevented?

There is no known way of preventing hydroceles. It is not due to anything a mother did during pregnancy.

How is a hydrocele diagnosed?

The doctors will feel your child’s scrotum to see if the swelling is caused by fluid or something solid. This can also be confirmed with an ultrasound scan.

How is a hydrocele treated?

Most hydroceles go down within a few months of birth, but occasionally they last longer. If a hydrocele is still present after the first birthday or is causing any problems, an operation might be suggested. Surgery for hydrocele is the same as that for a hernia wherein the passage through which the fluid or the bowel comes down from the abdomen is closed.

What does the operation involve?

The operation is carried out under general anaesthetic and lasts for about 30 – 45 minutes. Once your child is asleep, the surgeon will make a small incision (cut) on the lower abdomen to remove the fluid inside your child’s scrotum. The passage between the abdomen and scrotum will then be sealed off. The cut will be closed with dissolvable stitches.

Can this operation be done laparoscopically?

Operation in hydrocele involves closing of the open passage through which the testis has come down. This can be done from outside as in open surgery or from inside by laparoscopy. With the help of laparoscopy we are able to look at the opposite side to see if the passage is open on that side as well. This can be closed at the same sitting if you wish to. Recovery from surgery, timing of surgery and discharge from hospital are the similar for open surgery and laparoscopic surgery.

However, it is important to note that an open passage does not always mean that your child will get a hydrocele or hernia on the opposite side. There is no harm in opting for a second surgery later if your child at all develops a hernia on the opposite side.

Laparoscopic repairs have a slightly higher chance of recurrence as compared to open surgery. You can discuss the pros and cons in details with your doctor when you come for consultation. What are the risks of surgery?

After an anaesthetic some children may feel sick and vomit. They may have a headache, sore throat or feel dizzy. These side effects are usually short-lived and not severe. Some children develop swelling over the scrotum 24 hours after surgery. This gradually resolves on its own over the course of the next week.

What happens after the operation?

Your child will recover from the anaesthetic on the ward. Once he feels comfortable and has something to drink and eat, you will be able to take your child home. We recommend that you bring in some loose clothing for your child to wear home and for the next few days, as this will be a lot more comfortable.

What happens after you go home?

Your child should not have a bath or shower for three to five days after the operation. After this, it is fine for your child to have a shower, but try to avoid long baths as this may cause the scab to soften and fall off too early.

Your child should be ready to go back to school or nursery about a week after the operation. The stitches will dissolve on their own within two weeks or so. You will need to visit hospital for a follow up check 7 – 10 days after surgery.

What is a hernia?

A hernia describes a small piece of abdominal lining, and sometimes a section of the bowel, which bulges out through the abdominal wall. Both children and adults can have hernias. Sometimes it is present at birth. The hernia can look bigger when your child cries or strains.

What causes a hernia?

While your child was developing in the womb, the testicles were developing inside the abdomen. Towards the end of pregnancy, the testicle travel through a passage into the scrotum. When this passage fails to close the intestines in the abdomen tend to bulge out through it causing a hernia. Unlike adults, there is no generalized weakness of the abdominal wall that causes hernia in children. Sometimes the passage through which the testis has come down may be small allowing only fluid around the intestines to come down. This is called a ‘hydrocele’.

How common are hernias in children?

Hernias are more common in boys than girls. About one in 50 boys will have a hernia during their childhood. The condition is also more common in babies born prematurely.

Is it possible to prevent a hernia?

There is no known way of preventing a hernia.

How is a hernia diagnosed?

Your doctor will be able to diagnose the hernia by clinical examination as it appears as a characteristic lump in your child's abdomen. Your child may not need any further diagnostic investigations.

How are hernias treated?

Your child will need a small operation. In many cases this can be carried out as day surgery - your child will arrive at the hospital, have the operation and be able to go home on the same day. Occasionally a child will need to stay in hospital for a day or two.

Hernias in children do not need placing a mesh or a net as is used in adult hernia repairs. The reason for this is that in children cause for the hernia is completely different than in adults where hernia is caused because of the weakness of the abdominal muscles.

At what age should the child have surgery for hernia?

Hernia should be operated earliest after the diagnosis, irrespective of your child’s age or weight. Untreated hernias are known to have complications in the form of obstruction where the intestine gets stuck and fails to go back in the abdomen. This will then require emergency treatment.

Remember: "SMALLER THE CHILD AND SMALLER THE HERNIA, GREATER THE RISK OF OBSTRUCTION."

Children with obstructed hernias

What does the operation involve?

The operation is carried out under general anaesthetic and lasts for about 30 – 45 minutes. Once your child is asleep, the surgeon will make a small incision (cut) on the lower abdomen, The abdominal lining and piece of bowel will be pushed back into place. The open passage will be repaired and closed with stitches. These stitches will dissolve and will not have to be removed.

Can this operation done by laparoscopy?

Operation in hernia involves closing of the open passage through which the testis has come down. This can be done from outside as in open surgery or from inside by laparoscopy. If your child has got a hernia on one side, there is a 15 – 25 % chance that he / she may develop a hernia on the opposite side at a later date. With the help of laparoscopy we are able to look at the opposite side to see if the passage is open on that side as well. This can be closed at the same sitting if you wish to. Recovery from surgery, timing of surgery and discharge from hospital are the similar for open surgery and laparoscopic surgery.

However, it is important to note that an open passage does not always mean that your child will get a hernia. There is no harm in opting for a second surgery later if your child at all develops a hernia on the opposite side. Laparoscopic repairs have a slightly higher chance of recurrence (i.e. the hernia coming back again) as compared to open hernias. You can discuss the pros and cons in details with your doctor when you come for consultation.

What are the risks of surgery?

After an anaesthetic some children may feel sick and vomit. They may have a headache, sore throat or feel dizzy. These side effects are usually short-lived and not severe. Some children develop swelling over the scrotum 24 hours after surgery. This gradually resolves on its own over the course of the next week.

What happens after the operation?

Your child will recover from the anaesthetic on the ward. Once he feels comfortable and has something to drink and eat, you will be able to take your child home. We recommend that you bring in some loose clothing for your child to wear home and for the next few days, as this will be a lot more comfortable.

What happens after you go home?

Your child should not have a bath or shower for three to five days after the operation. After this, it is fine for your child to have a shower, but try to avoid long baths as this may cause the scab to soften and fall off too early.

Your child should be ready to go back to school or nursery about a week after the operation. The stitches will dissolve on their own within two weeks or so. You will need to visit hospital for a follow up check 7 – 10 days after surgery.

Are there any long term effects of hernia repair?

Most hernia repair operations are successful. You should see an immediate reduction or the complete disappearance of the hernia.

One out of ten children develops a hernia on the opposite side of the body. This risk is doubled if your child has been born prematurely.

What is a haemangioma?

A haemangioma is a collection of small blood vessels that form a lump under the skin. They are sometimes called ‘strawberry marks’ because the surface of a haemangioma looks a bit like the surface of a strawberry. Haemangiomas can be superficial or deep. Some haemangiomas are a combination of the superficial and deep kinds, with a raised, red area on the surface of the skin, and a bluish swelling of abnormal blood vessels deeper in the skin.

What causes haemangiomas?

There is now some scientific evidence to suggest that nearly three quarters of haemangiomas may be caused by placental tissue. If a tiny piece of tissue from the placenta embeds into the baby’s developing tissue very early in pregnancy, this can start to grow on his or her skin after the baby is born, forming a haemangioma. We do not yet know fully what might cause the placental tissue to embed. Other theories have evolved, but more research is needed to confirm the causes of haemangiomas.

How common are haemangiomas?

About one in every ten babies has a haemangioma. They are more common in girls, in premature babies, low birth weight babies and multiple births, such as twins, triplets and quadruplets. Haemangiomas are not inherited, but because they are quite common, families often report another relative who has had a haemangioma in childhood.

What do haemangiomas look like?

Superficial haemangiomas are usually a raised, bright red area of skin, which feels quite warm because the abnormal blood vessels are close to the surface. A superficial haemangioma may appear initially as a small area of pale skin on which a red spot develops.

Deep haemangiomas may appear bluish in colour because the abnormal blood vessels are deeper in the skin. Sometimes they are not noticeable for the first few weeks, only appearing as a lump as the haemangioma grows; this is particularly true if the surface of the skin is not affected.

Haemangiomas are not usually present at birth but develop a few days or weeks later. They often grow rapidly in the first three months, increasing in size and sometimes in redness. It is unusual for haemangiomas to grow after six to ten months of age, when most haemangiomas tend to have a ‘rest period’ and then begin to shrink.

Where do haemangiomas occur?

Most children only develop one haemangioma, but occasionally, a child has multiple haemangiomas in various parts of the body. This seems to happen most often in twins or other multiple births. Haemangiomas can appear anywhere on the body. The majority of haemangiomas appear on the head or neck, particularly on the cheek, lips or upper eyelid. Haemangiomas can also appear on the organs inside the body. This is most common when a child has multiple haemangiomas. The organ most commonly affected is the liver, but occasionally the airway, heart and brain may also be involved. Babies with multiple haemangiomas should have an ultrasound scan to confirm this or rule it out.

How are haemangiomas diagnosed?

Superficial haemangiomas are clearly noticeable and quite different to other types of birthmark so no special diagnostic tests are usually needed.

A child with a haemangioma near the eye, or a deep haemangioma, or one affecting the internal organs may require ultrasound and/or MRI scans to confirm the diagnosis, location, and also to check the depth of the affected blood vessels.

Looking after your child’s haemangioma

In most cases, haemangiomas just need looking after carefully.

As the blood vessels in a haemangioma are so near the surface of the skin, they can bleed if they are knocked or scratched. It is important to keep both your nails and your children’s nails cut short and buffed smooth, so that they don’t catch the surface of the haemangioma.

If the haemangioma starts to bleed, apply pressure over it with a clean handkerchief, cloth or tissue for at least five minutes. If blood soaks through the handkerchief, cloth or tissue, put another one on top and keep up the pressure. Do not take it off to have a look as this could start the bleeding again. If the bleeding continues, even after pressing down on the haemangioma for five minutes, go to your nearest doctor or contact us at the numbers provided.

The surface of the haemangioma is delicate and can be very dry, so avoid using bubble baths and rinse any soap or shampoo off carefully and pat the area gently afterwards. A thin layer of coconut oil or jelly (Vaseline etc.) put gently over the top of the haemangioma can stop it drying out. Haemangiomas need protection from the sun because it can make them swell up for a while and look redder. You can use sun protection cream on all areas of exposed skin or use a hat to protect your child’s face and/or an umbrella when the baby is outdoors.

When might my child’s haemangioma need treatment?

Most haemangiomas do not require any treatment, but there are circumstances when treatment might be needed. Occasionally, haemangiomas can form an open sore or ulcer, which is painful. Ulcers can become infected, so a visit to your doctor is important, as infected ulcerated areas may need treatment with antibiotics. Haemangiomas that are around the mouth, in the nappy area or in natural folds of skin, like the armpit, ear and neck, are most likely to become ulcerated. This is often due to the friction of the two surfaces of skin rubbing together.

A child with a haemangioma around the mouth can suck or chew the lip/ haemangioma, and feeding, either by breast or bottle, can irritate the area further.

The nappy can rub haemangiomas in the nappy area, and contact with stools or urine makes the ulcer more painful. Wherever the haemangioma is located, an ulcer is painful, more likely to bleed, and more likely to become infected. In the long term, an ulcerated area is more likely to leave a scar than a non-ulcerated area of haemangioma. If your child’s haemangioma develops an ulcer, it will need special attention until it heals. Keep the area clean by washing it twice a day, preferably in a bath or by pouring water over the area, and leave it to dry naturally. Haemangiomas near the eye

Haemangiomas near the eye can have long-term effects on a child’s vision, so need to be checked by a specialist eye doctor (ophthalmologist). The haemangioma can press on the eyeball, causing it to go slightly out of shape, affecting how images are focused on the retina, which in turn alters the messages sent to the brain from the eye. Haemangiomas that are blocking vision may need treatment with steroid medicines, given either as a liquid by mouth or in certain cases, as an injection directly into the haemangioma.

Haemangiomas on the lips

Haemangiomas on the lips often become ulcerated, and because ulcers are so painful, the child may not want to feed. Giving your child pain relief, before feeding can help. It can also help to put some Vaseline on the teat of the bottle (or around your nipple if you are breast feeding) will reduce friction and make feeding less painful.

Treatment options

There are lots of treatment options available; which option is suggested depends on the size and location of your child’s haemangioma.

Haemangiomas are painful when they are ulcerated, so your child may need regular pain relief. Antibiotics

Antibiotics are recommended when an infection of an ulcerated haemangioma is suspected. These are usually given in the form of a cream or ointment to put directly on the ulcerated area, but widespread infection may need antibiotics in the form of tablets or a liquid as well. Occasionally, a child might need intravenous (into a vein) antibiotics and a stay in hospital.

Steroids

Steroids may be needed when the haemangioma is near the eye, lips, or nappy area to limit further growth. They are usually given as tablets or a liquid, and need to be given exactly according to instructions. When the haemangioma has shrunk enough, the dosage is gradually reduced, as it can be dangerous to stop steroids suddenly.

Laser Treatment

Laser treatment is sometimes used in the treatment of haemangiomas. It can be useful if used early in the development of flat haemangiomas, as it reduces the redness and also reduces the risk of ulceration. Laser treatment is also helpful if an ulcer has already developed, as it reduces the pain of the ulcer, makes it heal faster and reduces the risk of infection.

Immunosuppressive Medicines

A medicine called vincristine is occasionally used to treat specific types of haemangioma in infancy. This medicine is usually used to treat certain forms of cancer and leukaemia, but the doses used to treat these specific haemangiomas are much smaller. It is usually given alongside steroid medicines, particularly if they have not reduced the swelling.

Embolisation

Embolisation is a procedure to ‘block off’ certain blood vessels by injecting them with a ‘glue-like’ substance or beads that stop the blood flowing through them. Generally, this is only used when haemangiomas are very troublesome and other treatments have had little effect.

Surgery

Sometimes, surgery is an option for removing haemangiomas. The surgeon removes the haemangioma tissue and joins the healthy skin together. There will always be a scar with this sort of operation, but it varies depending on the location and size of the haemangioma. Sometimes, it is better to wait until the haemangioma has resolved completely, and see whether surgery is needed at that point.

What are the long term effects of a haemangioma?

Most haemangiomas will have disappeared completely by the age of five to seven years. Large haemangiomas may continue to get smaller until your child is about eight to ten years old.

Depending on the size and location of the haemangioma, there may be little sign it ever existed. Occasionally the affected area of skin might be a bit lighter in color than the rest of your child’s skin. Large haemangiomas may distort the surrounding skin and even when they disappear, leave behind an area of stretched skin that looks puckered or wrinkled. This can often be improved with cosmetic surgery. Some children may have an uneven skin texture once the haemangioma has resolved. Some children may have some leftover fatty tissue.

Hirschsprung’s disease is a rare disorder of the bowel, most commonly the large bowel (colon), which can lead to severe constipation and intestinal obstruction. Hirschsprung’s disease affects one in every 5,000 babies. Normally, the muscles in the bowel squeeze rhythmically to push faeces (stools) through to the rectum. In Hirschsprung’s disease, the nerves that control these muscles (ganglion cells) are missing from part of the bowel. This means that stools cannot be pushed through the bowel in the usual way. The length of the affected part of bowel varies from child to child. Most commonly the rectum and/or sigmoid colon (the last parts of the large bowel) are affected. The entire colon is affected only very rarely.

What causes Hirschsprung’s disease?

Hirschsprung’s disease is a congenital (present at birth) disorder. While your baby was developing in the womb, the nerve cells did not develop through the full length of the bowel. We do not know what caused this to occur, but it was not due to anything that happened during pregnancy. A number of genes causing Hirschsprung’s disease have now been identified, although not all children have a specific genetic mutation.

What are the signs and symptoms of Hirschsprung’s disease?

The main symptom of Hirschsprung’s disease is constipation, which cannot be treated using laxatives or softeners. This occurs because faeces (stools) are pushed through the bowel until they reach the affected part. As this part of the bowel cannot squeeze rhythmically to push the faeces (stools) through the bowel, the faeces cannot move any further. As more food is digested and turned into faeces, the bowel becomes blocked causing discomfort and a swollen abdomen. Often babies with Hirschsprung’s disease do not pass meconium – the dark faeces passed in the first day of life. Other symptoms include a swollen abdomen and green vomiting (bile).

How is Hirschsprung’s disease diagnosed?

Hirschsprung’s disease can be suggested on x-rays, either a plain x-ray or a contrast / barium enema. Some sections of the bowel look very bulged but the section after looks narrower than usual. It is more reliably diagnosed by taking a small piece of tissue from the bowel to examine under a microscope. This is called a rectal biopsy. If the piece of tissue does not have any ganglion cells, this means Hirschsprung’s disease has been diagnosed.

How can Hirschsprung’s disease be treated?

How Hirschsprung’s disease is treated depends on the age at which your child is diagnosed and how well your child is generally. All children will require surgery at some stage. Some children’s constipation can be helped on a short-term basis using enemas (bowel washouts), where a thin tube is inserted into your child’s bottom and filled with a warm saltwater solution. This softens the faeces and flushes it from your child’s bowel. If a child is newborn or generally well, we may suggest treating the Hirschsprung’s Diseaselaparoscopically in one operation called a ‘laparoscopic assisted pull-through’ operation. This is where the affected part of the bowel and then connects the healthy section directly to the anus to allow faeces to be passed. If a child is older or not very well, we may suggest a staged operation. First, we will create an artificial opening (stoma) for the bowel as a temporary measure. This will allow your child to pass faeces through the stoma, allowing their health to improve before the pull-through operation. In the event of the child already having a stoma prior to visiting this hospital, a laparoscopic pull through operation is still possible.

Are there any alternatives other than surgery ?

No. Eventually, all children will need surgery to treat the Hirschsprung’s disease.

What happens before the operation?

The child will need to come into hospital two - three days before the operation. This is so your child’s bowel can be empty of faeces(stools) and ready for the operation. He or she may have laxatives or a bowel washout, and will be allowed to drink clear fluids for 24 hours before the operation.

What does the operation involve?

The surgeon will identify the part of the bowel missing the ganglion cells using a series of biopsies and remove it. Once they have removed the affected portion of bowel, they will attach the end to the anus to create a working bowel, with enough nerve cells to control the muscles so that your child can pass faeces as usual. If your child is having a staged repair, a stoma may need to be formed first so that they can get better before they have the pull-through operation. As with the pull-through operation, the surgeon will identify the affected portion of bowel using a series of biopsies and remove it. They will then bring the end to an artificial opening in your child’s abdomen called a stoma. This means faeces can be pushed through the bowel to the stoma, where they are collected in a bag to be disposed of later. Some weeks later, in another operation, the surgeon will remove the part of the bowel missing the ganglion cells as in the ‘pull-through’ operation. The stoma will be closed when your child has had the pull through operation, either during the same procedure or a few weeks or months later.

Are there any risks?

Every anaesthetic carries a risk of complications, but this is very small. Your child’s anaesthetist is an experienced doctor who is trained to deal with any complications. All surgery carries a small risk of bleeding during or after the operation. There is a very small chance that the bowel could leak into the abdominal cavity. If this occurs, your child will need a stoma as this reduces the risk of developing a serious infection called peritonitis.

What happens afterwards?

The child will come back to the ward to recover. We will keep your child as comfortable as possible by giving regular pain relieving medications. For the first few days, the pain relief will usually be given through a ‘drip’ and then, when your child is more comfortable, in the form of medicines to be swallowed. For the first few days, your child will need a ‘drip’ of fluids until they feel like eating and drinking again. This will also allow the bowel to rest and start to heal. You will be able to go home once he or she is comfortable.

When you get home

After the pull-through operation, your child may have soreness around the anus when passing faeces normally. You can try using coconut oil to clean your child’s bottom, as this will also ease any discomfort. It will also help to use nappy cream after each nappy change. We will discuss this further with you before you go home. Whenever possible, leave your child’s bottom open to the air as this will help it heal too.

Are there any long-term effects of the operation?

Although the pull-through operation is very successful at treating Hirschsprung’s disease some children develop problems afterwards, some of which we are able to treat. Constipation may be seen after the pullthrough operation, which may require treatment with medications. Toilet training in children who have had the pull-through operation may be delayed, mainly due to having to learn to coordinate the nerves and muscles in the rectum and anus. Children should follow a normal balanced diet after the pull-through operation. Sometimes children with Hirschsprung’s disease can develop an infection called Hirschsprung’senterocolitis. If your child develops diarrhoea.If not responding to oral medications, the child may need to come into hospital for a short stay to receive treatment with fluids and antibiotics.

What is the outlook for children with Hirschsprung’s disease?

Overall, the outlook for children with Hirschsprung’s disease is good, with the majority growing up to live normal lives, working and raising a family.If you have a child with Hirschsprung’s disease, future children may be at increased risk of also having this condition.


What is intussusception?

Intussusception is a condition where the bowel ‘telescopes’ in on itself. This causes the bowel walls to press on one another, blocking the bowel. This can lead to reduced blood flow to that part of the bowel. Picture of Intussusception with bowel in bowl appearance

What are the symptoms?

The main symptom of intussusception is severe abdominal pain that comes and goes. Each episode (time) tends to last two to three minutes. After 12 hours or so, the pain become more constant, and your child will usually go off food and may vomit.

Your child’s stools may contain blood and mucus. Due to the vomiting, your child may become dehydrated. Symptoms of dehydration include lethargy (tiredness), reduced urine output than usual. Your child may also have a high temperature and a swollen stomach.

How is intussusception diagnosed?

Your doctor will generally be able to feel the intussusception by pressing gently on the abdomen to feel for the swollen bowel. An ultrasound scan will usually confirm the diagnosis.

What causes intussusception?

We are not sure what causes the bowel to telescope in on itself, but there may be some link to infections.

How common is intussusception and whom does it affect?

Intussusception is the most common cause of bowel blockage in infants and young children. It tends to happen between the ages of three and 18 months.

How intussusception is treated and are there any alternatives?

Intussusception can cause reduced blood flow to part of the bowel, which would stop it functioning properly and can also lead to problems with infection. The effects of intussusception, like dehydration due to vomiting, can become serious quite quickly in children, so the condition needs emergency treatment. If your child is dehydrated, he or she will need a drip of fluids for a while before treatment starts. Your child will also need a nasogastric tube, which is passed up the nose, down the food-pipe and into the stomach. This will drain off the stomach and bowel contents, and ‘vent’ any air that has built up, which will make your child more comfortable.

An enema is usually the first treatment. A tube is inserted into your child’s bottom and air or oxygen is released into the bowel. This works by expanding the bowel, so that the intussusception corrects itself. If the enema works well, you will be able to return home in a day or so. If your child is not well enough to have an enema, or if the enema did not reduce the intussusception, your child will need an operation under general anaesthetic.

What does the operation involve?

Your child’s surgeon will gently squeeze the bowel to push out the inner segment. He or she will also examine the bowel to see if there is blood flow to that part of the bowel and if it looks healthy. Nowadays, this operation can also be done with the help of laparoscopy in selected cases. The surgeon will remove any part of the bowel where tissue has died due to the lack of blood flow. The amount can vary, but the surgeon will leave as much bowel as possible.

What happens afterwards?

Your child will not be able to feed for about 24 – 48 hours which will allow the bowel to recover. He or she will continue to have a drip of fluids and the nasogastric tube to drain off the stomach contents. After a couple of days, your child will be able to feed again, starting with small amounts and increasing the amount as he or she tolerates it. When your child’s bowel has recovered completely, you will be able to feed him or her solids. The doctors will let you know when this is likely.

Your child will be able to go home once he or she is feeding well. This is usually about 3-5 days or so after the operation.

What is the outlook for children with intussusception?

The outlook is good, with the majority of children having no further bowel problems. However, intussusception can come back in a small number of children, which will require further treatment either by enema or an operation.

What is a hernia?

A hernia describes a small piece of abdominal lining, and sometimes a section of the bowel, which bulges out through the abdominal wall. Both children and adults can have hernias. Sometimes it is present at birth. The hernia can look bigger when your child cries or strains.

What causes a hernia?

While your child was developing in the womb, the testicles were developing inside the abdomen. Towards the end of pregnancy, the testicle travel through a passage into the scrotum. When this passage fails to close the intestines in the abdomen tend to bulge out through it causing a hernia. Unlike adults, there is no generalized weakness of the abdominal wall that causes hernia in children. Sometimes the passage through which the testis has come down may be small allowing only fluid around the intestines to come down. This is called a ‘hydrocele’.

How common are hernias in children?

Hernias are more common in boys than girls. About one in 50 boys will have a hernia during their childhood. The condition is also more common in babies born prematurely.

Is it possible to prevent a hernia?

There is no known way of preventing a hernia.

How is a hernia diagnosed?

Your doctor will be able to diagnose the hernia by clinical examination as it appears as a characteristic lump in your child's abdomen. Your child may not need any further diagnostic investigations.

How are hernias treated?

Your child will need a small operation. In many cases this can be carried out as day surgery - your child will arrive at the hospital, have the operation and be able to go home on the same day. Occasionally a child will need to stay in hospital for a day or two.

Hernias in children do not need placing a mesh or a net as is used in adult hernia repairs. The reason for this is that in children cause for the hernia is completely different than in adults where hernia is caused because of the weakness of the abdominal muscles.

At what age should the child have surgery for hernia?

Hernia should be operated earliest after the diagnosis, irrespective of your child’s age or weight. Untreated hernias are known to have complications in the form of obstruction where the intestine gets stuck and fails to go back in the abdomen. This will then require emergency treatment.

Remember: "SMALLER THE CHILD AND SMALLER THE HERNIA, GREATER THE RISK OF OBSTRUCTION."

What does the operation involve?

The operation is carried out under general anaesthetic and lasts for about 30 – 45 minutes. Once your child is asleep, the surgeon will make a small incision (cut) on the lower abdomen, The abdominal lining and piece of bowel will be pushed back into place. The open passage will be repaired and closed with stitches. These stitches will dissolve and will not have to be removed.

Can this operation done by laparoscopy?

Operation in hernia involves closing of the open passage through which the testis has come down. This can be done from outside as in open surgery or from inside by laparoscopy. If your child has got a hernia on one side, there is a 15 – 25 % chance that he / she may develop a hernia on the opposite side at a later date. With the help of laparoscopy we are able to look at the opposite side to see if the passage is open on that side as well. This can be closed at the same sitting if you wish to. Recovery from surgery, timing of surgery and discharge from hospital are the similar for open surgery and laparoscopic surgery.

However, it is important to note that an open passage does not always mean that your child will get a hernia. There is no harm in opting for a second surgery later if your child at all develops a hernia on the opposite side. Laparoscopic repairs have a slightly higher chance of recurrence (i.e. the hernia coming back again) as compared to open hernias. You can discuss the pros and cons in details with your doctor when you come for consultation.

What are the risks of surgery?

After an anaesthetic some children may feel sick and vomit. They may have a headache, sore throat or feel dizzy. These side effects are usually short-lived and not severe. Some children develop swelling over the scrotum 24 hours after surgery. This gradually resolves on its own over the course of the next week.

What happens after the operation?

Your child will recover from the anaesthetic on the ward. Once he feels comfortable and has something to drink and eat, you will be able to take your child home. We recommend that you bring in some loose clothing for your child to wear home and for the next few days, as this will be a lot more comfortable.

What happens after you go home?

Your child should not have a bath or shower for three to five days after the operation. After this, it is fine for your child to have a shower, but try to avoid long baths as this may cause the scab to soften and fall off too early.

Your child should be ready to go back to school or nursery about a week after the operation. The stitches will dissolve on their own within two weeks or so. You will need to visit hospital for a follow up check 7 – 10 days after surgery.

Are there any long term effects of hernia repair?

Most hernia repair operations are successful. You should see an immediate reduction or the complete disappearance of the hernia.

One out of ten children develops a hernia on the opposite side of the body. This risk is doubled if your child has been born prematurely.


The intestines form early in pregnancy as a long straight tube. Before the tenth week of pregnancy, they develop into the separate organs making up the digestive system. Occasionally, the intestines are not completely connected or blocked (atresia). Sometimes there is a partial blockage (web) inside the intestine. Any part of the intestines can be affected by atresia or stenosis. Duodenal Atresia is one type. This occurs in around one in 6,000 births where the duodenum is closed off rather than being a tube. If the jejunum or ileum are affected, this is called ‘small bowel atresia’. Small bowel atresia is more common than duodenal atresia. We do not know how exactly how many babies are born with small bowel atresia each year but we do know that it affects boys and girls equally. It is more common in twins or multiple births and babies born prematurely or with low birthweight. Colonic atresia, affecting the large bowel, is very rare. Small bowel atresia affects two areas of the small bowel – the jejunum and the ileum. The jejunum is the section of small bowel after the duodenum and is where the majority of nutrients are absorbed. The ileum is the main part of the small bowel, making up over half of its entire length, and connects to the large bowel. The blockage can affect any part of the ileum or jejunum.

What causes small bowel atresia?

More research is needed into the causes of small bowel atresia but currently doctors think that it is caused by reduced blood supply to sections of the bowel as the baby is developing in the womb. It is unlikely that it is caused by anything you did or did not do during pregnancy.

What are the signs and symptoms of small bowel atresia?

Many babies born with small bowel atresia appear well at birth but when they start to feed, they start to have nausea and vomiting and their vomit may be green. Their abdomen may appear swollen but soft and their skin may develop a yellow tinge (jaundice). All newborn babies have meconium in their bowel. This is the dark green stool passed in the first day of life. Babies born with small bowel atresia may not pass any meconium at all or only a small amount. Not passing meconium does not prove that a baby has small bowel atresia but it may suggest it. Some babies with small bowel atresia pass meconium as expected.

How is small bowel atresia diagnosed?

When a baby with small bowel atresia is developing in the womb, they are may be surrounded by much more amniotic fluid than usual (polyhydramnios). Small bowel atresia can sometimes be suggested during pregnancy using an ultrasound scan. After the baby is born, small bowel atresia is usually diagnosed when there are signs of an obstruction, such as vomiting, green bile and a swollen abdomen. An x-ray scan may show a blockage. Occasionally, doctors may suggest using a contrast scan and/or enema instead or as well as an x-ray. Contrast scans and enemas use a thick, white liquid called barium or a clear liquid (contrast), both of which show up well on x-rays. The contrast cannot pass through the atresia suggests that atresia can be a cause.

How can small bowel atresia be treated?

Small bowel atresia is repaired in an operation under general anaesthetic. The operation to repair the atresia can is usually carried out using open surgery. Sometimes a laparoscopic surgery (key hole procedure) may help diagnose the problem so that it can be repaired using open surgery.

Are there any alternatives?

No. Small bowel atresia always requires surgical treatment to allow your baby to feed.

What happens before the operation?

Your baby will be transferred to the hospital soon after birth. If your child is dehydrated, they will need a ‘drip’ of fluids for a while before the operation. Your child will also need a nasogastric tube, which is passed up the nose, down the foodpipe and into the stomach. This will drain off the stomach and bowel contents and ‘vent’ any air that has built up, which will make your child more comfortable. When your child is stable, the surgeon will explain about the operation in more detail. Sometimes the atresia is suspected but may not be the only possible cause of the blockage. The surgeon will explain this to you.

What does the operation involve?

The surgeon will look at the bowel to determine the level of the blockage. If it is an atresia, this section is removed and the cut ends are joined together (anastomosis). This provides a clear passage for food and fluid to travel through your child’s intestine. The remainder of the small intestine will be checked for further atresias and treated if identified. If it is not possible or safe to join the two ends together during the same procedure, the surgeon may bring the end of the intestine to an artificial opening (stoma) in the abdomen to form an ileostomy.

Are there any risks?

All surgery carries a small risk of bleeding during or after the operation. There is a chance that the area where the two ends of bowel were joined could start to leak, allowing bowel contents to escape into the abdomen. This is usually treated with antibiotics, but a second operation may be needed to check the leaking portion. All abdominal surgery carries the risk of strictures forming. These are areas of scar tissue that can narrow the intestines, leading to obstruction. If your child vomits green bile and has a swollen abdomen, they should be reviewed urgently by a doctor. It can take a while after the operation for the bowel to start working properly so your child may need to be fed intravenously using total parenteral nutrition (TPN) for a while. This affects many children.

What happens after the operation?

While your child’s intestines recover and start to work, they may be fed through a tube into their veins (total parenteral nutrition or TPN). This will gradually be replaced by breast or bottled milk, given through the naso-gastric tube when your child is able to tolerate this. As your baby recovers, you will be able to feed them from the breast or bottle. Over time, the drips and monitors will be removed one by one.Most children stay in hospital for one to two weeks, but occasionally a longer stay is needed.

What happens next?

The outlook depends on the amount of damage to the bowel. Adhesions can form after any abdominal surgery and can cause further problems such as blockage or pain. This however is quite rare and may sometimes require another operation to separate the adhesions.


Kidney (or renal) stones are clusters of tiny crystals that can form in the kidneys. Most clusters are too small to cause any problems and pass out of the body in the urine. Sometimes, the clusters can clump together to form bigger clusters, which may eventually become big enough to block the filtering units in the kidney. Sometimes, they pass out of the kidney down the ureter and out in the urine without causing any problems, but if they are big they may block the ureter or lodge in the bladder. Kidney stones are much more common in adults than in children. Children who have kidney stones will be checked thoroughly to rule out or confirm an underlying condition causing the problem. This could include a structural abnormality with the urinary system or a problem with the metabolism.

What causes kidney stones?

The urinary system consists of the kidneys, ureters, the bladder and urethra. The kidneys filter the blood to remove waste products and produce urine. The urine flows from the kidneys down through the ureters to the bladder, where it is stored until we go to the toilet. It passes through another tube called the urethra to the outside when urinating. The kidneys contain millions of tiny filtering units called glomeruli. As blood passes through the tubes in the glomerulus, waste products pass through the walls of the tubes to form urine. Blood cells and other things such as protein cannot pass through the walls because they are too big.

The urine contains lots of different substances, which do not cause any problems when the urine is weak and the amount of each substance is balanced. However, when the urine becomes too concentrated, often due to dehydration, the proportion of these substances in the urine increases, which can make crystals form. They can also form if the amount of these substances increases because the body is making more of them than it should or not removing them normally. In rare situations, kidney stones can develop after urinary infections. Some children are more at risk of kidney stones, for instance, children who were born prematurely or those who have very limited mobility, such as those confined to wheelchair..

What are the signs and symptoms of kidney stones?

Some kidney stones do not cause any symptoms at all, particularly if they are very small and not causing a blockage. However, kidney stones can be painful and cause blood in the urine (haematuria) and generally feelings of being unwell, such as a high temperature and vomiting. If the stone passes out of the kidney into the ureter, it can cause severe pain. Kidney stones can cause an infection. Signs of an infection include a high temperature, vomiting and/or diarrhoea and urine that is pink or cloudy. Studies have shown that pain is not experienced in approximately half of young children with stones.

How are kidney stones normally diagnosed?

Apart from the history which is derived from asking you questions about the problem, various imaging scans may be needed to confirm the diagnosis, see where the kidney stones are located and their size. Anultrasound scan is usually the first test to help make the diagnosis, although other scans may be needed as well. Urine tests will be needed to show whether there is an infection and to measure the chemicals that cause stones. Blood tests will show how well the kidneys are working.

How are kidney stones normally treated?

This depends on their size and location. Smaller stones can be broken up using sound waves (lithotripsy). Some stones that are stuck in the ureter can be removed using an endoscope, a tube containing a small camera, a light and a laser device to break up the stone. Most other stones are removed using surgery through a small cut. The final decision as to how to remove the stone will vary from child to child and the number and size of stone and whether there are other problems related to the kidney or its drainage system that has caused the stone to form. Children with lots of stones or stones in both kidneys usually need several procedures to clear the stones. It is important to drink plenty of fluids to stop them forming again. Some children may need to reduce their salt intake and, rarely, other medicines or measures may be necessary.


What is laparoscopic or keyhole surgery?

Keyhole surgery, or laparoscopic surgery as it is also known, is a method of carrying out an operation without having to make a large incision. Many different types of operations can now be carried out using keyhole surgery. This type of surgery reduces the length of time your child needs to stay in hospital and leaves little scarring.

What are the advantages of keyhole surgery?

Children tend to recover more quickly after keyhole surgery and have fewer side effects. There is little scarring after keyhole surgery which becomes more important as your child grows older and becomes more self-conscious. One side effect of ‘open’ surgery - minimised with keyhole surgery - is ‘adhesions’. This is where internal organs stick together and form bands of scar tissue, which can be painful and cause obstruction. Adhesions have been proven to occur less often in adults after keyhole surgery, and the risk of adhesions in children after keyhole surgery is thought to be less as well.

Are there any risks?

Every anaesthetic carries a risk of complications but this is very small. Your child’s anaesthetist is an experienced doctor who is trained to deal with any complications. After an anaesthetic, children sometimes feel sick and vomit, may have a headache, sore throat or feel dizzy. These effects are short-lived. Any surgery carries a small risk of infection or bleeding.

After the operation, some older children may complain of shoulder pain. Your child may also feel some crackling under the skin because the carbon dioxide sometimes escapes into the tissue just under the skin. These side effects are usually short-lived and do not require any specialized care.

There is always a chance that keyhole surgery will not be possible for your child. Sometimes the surgeon will not be able to carry out an operation using the keyhole method for technical reasons or because of unexpected findings. If this is the case, the surgeon will carry out the operation using a larger incision instead.

Are there any alternatives to keyhole surgery?

All operations carried out as keyhole surgery can also be carried out using ‘open’ surgery, that is, with a larger incision.

What does the operation involve?

Your child will be given a general anaesthetic and will be asleep during the operation. Once your child is asleep, the surgeon inserts a small tube called a cannula into your child’s tummy button. A telescope, with a miniature video camera mounted on it, is inserted into this tube to project a very high quality video image onto a television screen. The abdomen is then inflated with carbon dioxide to create space in which the surgeon can operate. The operation is performed by inserting specialized instruments which are passed through small hollow tubes which are inserted through separate very small incisions. There may be two or more small incisions required to perform the operation.

Lymphatic malformations: (Also read Cystic Hygroma) A lymphatic malformation is an area in the body containing clear fluid, called lymph. A lymphatic malformation appears as a lump just under the skin, often in the neck or armpit, although they can develop anywhere in the body. The lump can enlarge the area of the body, for instance, if it appears in the lip area, it can enlarge the lip dramatically. Small surface lymphatic malformations can look like small bubbles under the skin.

Lymphatic System:

The lymphatic system forms part of the immune system that identifies and fights off invaders, such as bacteria and viruses. There is a network of vessels within the body through which lymph circulates. Lymph nodes are located in the neck, armpits and groin areas and filter the lymph fluid. When bacteria are found in the lymph fluid while it is being filtered, the lymph nodes release immune cells to fight the infection.

How is a lymphatic malformation diagnosed?

Lymphatic malformations are clearly noticeable. Diagnostic tests such as ultrasound scans, CT scans or MRI Scans may be required to confirm the diagnosis and also to understand the extent of the lymphatic malformation.

What causes lymphatic malformations?

A lymphatic malformation occurs when the lymph vessels fail to form correctly during the first few weeks of pregnancy.

Can they be prevented?

No, as they occur so early in pregnancy, usually before it is confirmed, they cannot be prevented. The effects of the lymphatic malformation however can be reduced or prevented. Lymphatic malformations often swell and become tender or painful when infected. If infections develop, they should be identified and treated promptly.

When might a lymphatic malformation need treatment? There are circumstances when treatment might be needed. Location of the malformation I

f a lymphatic malformation is in a place where it could interfere with breathing or feeding when it swells, it may need to be treated. This tends to affect lymphatic malformations in the neck area and those in or around the mouth, for instance, affecting the tongue.

Recurrent infections

If a child develops infections frequently and they are not controlled by antibiotics, other options for treatment using sclerotherapy or surgery may be considered.

Appearance

Lymphatic malformations, if large, can be visibly disfiguring and cause problems with unwanted attention at school.

How can lymphatic malformations be treated?

There are three main options for treatment: sclerotherapy, compression and surgical removal. Often they are used in combination, for example, sclerotherapy followed by compression or surgery followed by compression.

Sclerotherapy

Sclerotherapy is a procedure carried out by an interventional radiologist, who blocks the lymphatic vessels by injecting a special substance into them through the skin under general anaesthetic. Once a vessel has been blocked, it shrinks and becomes less noticeable. It may take several sclerotherapy sessions for the malformation to be completely treated and even then, it might grow again.

Compression

Specially made compression garments should help swollen areas and reduce discomfort if worn for 8 to 12 hours a day. Garments are either made to measure or ready made. They need to be replaced regularly as the child grows or the garment wears out. They will also need to be washed daily and dried at room temperature. Compression garments can be helpful in making sport and exercise more comfortable as they support the malformation and reduce swelling.

Surgical removal

Sometimes, particularly if the lymphatic malformation is quite small and is causing problems with function or appearance, it can be removed safely in an operation. Detailed scans will be needed to plan the operation. There will be an amount of scarring after the operation, as with all surgery. What is the outlook for children with a lymphatic malformation? Like the options available for treatment, this depends on the size and location of the malformation. Many children treated at this howpital are now leading normal lives, attending schools and college and working.

Everyone has lymph glands. They are in many areas of the body, including the neck, under the arms and in the groin (at the top of each leg). There are also lymph glands in the abdomen, chest and pelvis. Lymph glands are also known as lymph nodes. Lymph glands become enlarged when the body is fighting an infection, such as a cold. Enlarged lymph glands are particularly common in children as their body takes time to build up immunity to infection.

What causes swollen lymph glands?

Lymph glands swell as part of the body’s response to infection. Lymph glands are connected by vessels with branches right through the body, similar to the blood circulation system. Rather than carrying blood, these vessels carry a clear liquid called lymph, which contains a high number of white blood cells. Together with other organs (the spleen, tonsils, adenoids and thymus gland), they form what’s known as the lymphatic system. It has several functions but one of its key roles is fighting infection. When the body is fighting an infection, the number of white blood cells multiplies rapidly. Some of these cells will go to the lymph gland nearest the infection, which produces enlargement of the lymph glands. Children often have infections as it takes time for them to build immunity to the viruses and bacteria in the environment. Children who have recently started playgroup or nursery are especially prone because they are coming into contact with a large group of children of the first time.

What are the signs and symptoms of enlarged lymph glands?

The lymph glands will appear swollen. They will also be uncomfortable. Children frequently get upper respiratory tract infections, such as an ear or throat infection. This means that swollen glands in the neck are particularly common.

How are enlarged lymph glands normally diagnosed?

A child’s doctor will feel their glands to check if they are swollen.

How are enlarged lymph glands treated?

Most cases of enlarged lymph glands are from infection. Once the infection is gone, the glands will get smaller and less tender over time. If the glands are particularly large, the doctor will check the child for any other symptoms or an underlying cause.

What happens next?

In most cases, enlarged lymph glands are not serious and the condition is common. Following an infection, it is normal for them to take some time for the swelling to go down. Enlarged lymph glands rarely indicate a more serious problem. Sometimes it is a sign of cancer, such as lymphoma, but this is rare.


What is a Mitrofanoff and why might my child need one?

The Mitrofanoff procedure creates a channel into the bladder through which a catheter (thin, plastic tube) can be inserted to empty the bladder of urine, instead of passing urine through the urethra. This channel - which looks like an extra belly button - is usually referred to as a ‘Mitrofanoff’, and is created in an operation under general anaesthetic.

Children who are incontinent (wet) may benefit from this procedure. It allows the bladder to be emptied several times a day, reducing the chance of the bladder leaking urine. It can be psychologically easier and physically less uncomfortable to insert a catheter into the Mitrofanoff rather than the urethra. It can also allow older children to lead a more normal life. The Mitrofanoff procedure is often used for children with bladder problems due to spina bifida, bladder exstrophy or bladder obstruction (posterior urethral valves).

What does the operation involve?

The surgeon will disconnect your child’s appendix from its usual position on the large intestine and open it up to form a tube. He or she will then connect one end to a small incision (cut) in your child’s bladder and the other end to another small incision in your child’s abdomen. The surgeon will also create a ‘valve’ where the tube joins the bladder, which squeezes shut as the bladder fills with urine. This will reduce the chance of urine leaking from the Mitrofanoff.

If your child has already had his or her appendix removed or if it is not suitable, the surgeon may need to use a piece of the small intestine to create the channel. The usual hospital stay is about seven days.

Are there any risks?

All treatments carry an element of risk, but this must be balanced against the quality of life without treatment. All surgery carries a risk of bleeding during or after the operation. Every anaesthetic carries a risk of complications, but this is very small. After an anaesthetic, your child may feel sick and vomit. He or she may have a headache, sore throat or feel dizzy. These side effects are usually short-lived and not severe.

Are there any alternatives?

Your child could catheterise using the urethra, which some children find quite difficult. Another alternative is to do nothing, and allow your child to remain wet.

What happens afterwards?

For the first day or two, he or she will have a drip giving fluids and medication, until the bowel starts to recover. The drip will be removed when your child starts eating and drinking again.

The surgeon will have inserted a catheter into the Mitrofanoff to keep it open. This should stay in place for three to four weeks after the operation.

What is spinal dysraphism?

In early development, the brain and spinal cord start as a tube-like structure called the ‘neural tube’ that is open at either end. These openings close within the first weeks of pregnancy, and the neural tube continues to grow and fold, eventually forming the brain and spinal cord.

If the tube fails to close properly, this results in a group of problems called ‘neural tube defects’. Spinal dysphraism is the term used to describe what happens when the spinal column (backbone) fails to form properly. This happens very early in pregnancy, before the end of the fourth week. There are two types of spinal dysphraism: open, also called spina bifida aperta or myelomeningocele, or closed, also called spina bifida occulta.

The open myelomeningocele type accounts for 75 per cent of all cases of spina bifida. In myelomeningocele, the neural tube has failed to close and the neural tissue is exposed at a place on the baby’s back called the ‘neural placode’. This most commonly happens in the baby’s lower back just above the bottom, but could occur anywhere along the spine. The myelomeningocele will look like a sac sticking out from your baby’s back.

Open Neural Tube Defects

In closed spinal dysphraism, the spinal cord (a tube-like structure containing nerves) and its coverings do not protrude through the back unlike in the open type. On its own, closed spinal dysphraism is unlikely to cause any problems, and many people have the condition without ever knowing it. However, it can be associated with other conditions that could lead to problems with movement and bladder control.

Closed Neural Tube Defect

Many children have a ‘tethered cord’, which is the term used when the lower end of the spinal cord is attached to the lower bones of the spinal column rather than hanging freely as it should. Normally the spinal column grows more quickly than the spinal cord, so that by the time the baby is born, the spinal cord has moved higher up the spinal column. If the cord is tethered, the spinal cord and nerves are stretched, reducing their ability to carry messages to and from the brain and causing pain. Growth spurts can stretch the spinal cord and nerves, causing problems with leg movement and bladder and bowel control.

What are the symptoms of closed spinal dysphraism?

In many people, there may be no symptoms at all. However, a birthmark, hairy patch or dermal sinus in the lower back area may lead doctors to suspect that a child has closed spinal dysphraism. Other children may develop repeated bouts of meningitis for which no cause can be found or may have problems keeping dry (urinary incontinence) that cannot be explained. If it not diagnosed until early childhood, the first sign might be weakness or unevenness of the legs or talipes (clubfeet) affecting one of both limbs. Back or leg pain might be a problem too. If these symptoms are due to a tethered cord they may get worse as the child grows. Treatment by surgery tends to be suggested only when a child shows signs that his or her condition is getting worse, for instance, movement becomes more problematic or urinary incontinence is making everyday life more difficult or painful.

How is closed spinal dysphraism diagnosed?

Initial suspicions may be raised through clinical examination but imaging scans are used to confirm the extent of the problem. Ultrasound or magnetic resonance imaging scans are the usual methods used.

How is closed spinal dysphraism treated?

If there are clinical symptoms that are getting worse, these may be reduced using surgery to release the tethered cord. This relieves pressure on the spinal cord and nerves and can improve leg symptoms in many cases. It is less successful in improving bladder and bowel problems but usually stops them getting any worse over time.

What does the operation involve?

At surgery, the surgeon will release the spinal cord from where it is tethered so that it can move as the child grows. If possible, the surgeon will reduce the size of a lipoma to relieve pressure on the spinal cord. After the operation, the incision on your child’s back will be closed and covered with a dressing.

Are there any risks?

The operation to detach a tethered cord is very specialized due to the complex arrangements of nerves in the area. There is always a risk that the nerves, or the spinal cord itself, could be damaged in the operation but if the surgeon believes that this may happen, he or she will stop the procedure. The aim of the operation is to stop your child’s symptoms from them getting any worse. There is no guarantee that this operation will remove your child’s symptoms or even improve them. This operation tends to improve leg symptoms more frequently than bladder and bowel symptoms.

What is the outlook for children with closed spinal dysphraism? Orthopaedic problems

In some cases, children may have developed leg and foot problems as a result of the closed spinal dysphraism. These can include clawing of the toes or very high arches, which in turn can lead to tightening of the Achilles tendon at the heel. This can affect one leg or both and if it is severe, we may refer your child to an orthopaedic surgeon for further treatment.

Where a child has scoliosis as a result of the closed spinal dysphraism, further treatment by an orthopaedic spinal surgeon may be required. Sometimes however, treatment of the dysphraism may reduce or even improve the progression of the spine curvature.

Bladder and bowel control

The nerves that control bladder and bowel function are contained in the lower portion of the spinal cord and so can be affected by closed spinal dysphraism. The degree to which bladder and bowel control is affected depends on the severity of the defect.

Problems associated with the bladder are largely due to incomplete emptying, which is caused by the messages from the bladder not being transmitted to the brain well enough. Incomplete emptying of the bladder can lead to urinary tract infections (UTIs) and backflow of urine towards the kidneys (reflux), sometimes severe enough to damage the kidney. Signs of bladder problems include: urinary incontinence or dribbling, recurrent infections, bedwetting at night, needing to urinate frequently or having difficulties potty training. Bowel incontinence (soiling) is a less common problem, and rarely occurs if there are no bladder control problems. Early diagnosis and treatment can help reduce these problems but rarely solve them completely.

Movement

Closed spinal dysphraism can lead to muscle wastage on one side, affecting the buttocks and calf. This is caused by the muscles on one side being used more and therefore becoming stronger than the other, due to the stretching of the nerves leading away from the spinal cord when the cord is tethered. This can result in numbness, unbalanced walking, painless skin lesions, stiffness and pain in the lower limbs and back, sometimes relieved with odd postures or lying down. The physiotherapist will advise you about strengthening these muscles and improving their function as much as possible.

What about future pregnancies?

There is now evidence that an adequate intake of folic acid can dramatically reduce the risk of neural tube defects occurring in future pregnancies. If you are planning a further pregnancy, we recommend that you take 4mg of folic acid each day for at least three months before conception and for the first three months of pregnancy. This dose is higher than the standard recommendation for women who have not previously had a child with spina bifida. If you have any concerns about future pregnancies, please feel free to contact us.

What is a myelomeningocele?

In myelomeningocele, the neural tube has failed to close and the neural tissue is exposed at a place on the baby’s back called the ‘neural placode’. This most commonly happens in the baby’s lower back just above the bottom, but could occur anywhere along the spine. The myelomeningocele will look like a sac sticking out from your baby’s back.

How is myelomeningocele treated?

Without the protective covering of skin, the spinal cord will become further damaged, spinal fluid often leaks from the area and there is a very high risk of infection. Surgery is usually recommended within the first few days of life. The aim of surgery at this stage is to put the spinal cord back into the spinal canal and repair the defect in the back so that the area is covered with normal, healthy skin.

The physiotherapist will see your child after the operation. He or she will assess how much strength your child has in each muscle group and measure his or her sense of feel. When taken together, muscle strength, sensation and reflexes give us a picture of how well the messages are getting from the brain to the arms and legs via the spinal cord. The physiotherapist will also give advice on how to position and handle your child to stretch out tight muscles and to help with normal development. Once your baby is recovering well, you will both be able to go home. We will need you to come back to the hospital between 10 and 14 days after the operation so that we can check the operation site, carry out an ultrasound scan of your baby’s head and measure his or her head circumference. The child is followed up on a regular basis.

What problems can myelomeningocele cause?

There are a number of problems that might face a child born with myelomeningocele. However, we want to emphasise that these vary a great deal from child to child and also may show up at different times during a child’s development.

Bladder function

There are a number of problems that might face a child born with myelomeningocele. However, we want to emphasise that these vary a great deal from child to child and also may show up at different times during a child’s development.

Hydrocephalus

The circulation of cerebrospinal fluid (CSF) is often disturbed in children with myelomeningocele. Either at birth or in the days and weeks following surgery, fluid may start to build up within the brain. This is called hydrocephalus and can result in increased pressure in the brain. If this occurs, an operation to place a shunt tube to divert the excess fluid from the brain to the abdomen is needed. This operation is needed in about 60 per cent of children with myelomeningocele.

Mobility

Myelomeningocele affects each child differently, and how each child moves around will vary too. Some children will need splints or walking aids, and others may move around more easily in a wheelchair. Your doctor will speak to you about how your child’s condition will affect their mobility.

What is the outlook for children with myelomeningocele?

The outlook for children with myelomeningocele has improved dramatically in recent decades. Intellectual prognosis is very good for the majority of children, most of whom will go on to full time education. Recreational and employment opportunities are better now than at any time in the past. However, this is a multidisciplinary approach and team work with parental support is a must for a good outcome.

What is malrotation?

Malrotation is an abnormality of the bowel, which happens while the baby is developing in the womb. Early in pregnancy, the bowel is a long straight tube leading from the stomach to the rectum. The bowel then moves into the umbilical cord temporarily while it develops into the large and small bowel.

Around the tenth week of pregnancy, the bowel moves back into the abdomen and coils up to fit into the limited space there. If the bowel does not coil up in the correct position, this is called malrotation.

What is volvulus?

This is a complication of malrotation and occurs when the bowel twists so the blood supply to that part of the bowel is cut off.

What are the symptoms of malrotation and volvulus?

Malrotation may not have any symptoms. Many people are never diagnosed with malrotation because it causes no problems. However, bands of tissue (adhesions), which block the first part of the small bowel (duodenum), can develop. This means food cannot easily pass through the duodenum to the rest of the bowel for digestion.

The symptoms of volvulus are usually the first sign of malrotation. They include sudden bouts of crying and pulling the legs into the body, which then stop suddenly. This is caused by cramps, as the bowel cannot push food and liquid past the twisted section of bowel. Vomiting is another symptom of volvulus, as your child is unable to digest food as usual.

If the condition is not treated, the child will become dehydrated which can be life-threatening. the symptoms of dehydration may appear in phases, and include lethargy and reduced urine output.

What causes malrotation and volvulus and how common are they?

We do not know exactly what causes malrotation and volvulus, but it is not due to anything that happened during pregnancy. Malrotation affects about one in every 2,500 to 3,000 babies, and boys and girls in equal numbers.

How is malrotation and volvulus diagnosed?

Malrotation and volvulus are usually diagnosed using x-rays. A barium x-ray may also be useful as it shows the feeds being unable to pass the twisted part of the bowel. The doctor may also suggest an ultrasound scan to get an indirect evidence.

How are they treated and are there any alternatives?

Adhesions and volvulus are usually treated in an operation under general anaesthetic. They both require emergency treatment as the bowel can die off from lack of blood-supply, which would stop it functioning properly and can also lead to problems with infection. The effects of the adhesions and volvulus, like dehydration due to the lack of fluids being absorbed, can become serious quite quickly in children, and so there are no alternatives to the operation.

What happens before the operation?

If your child is dehydrated, he or she will need a ‘drip’ of fluids for a while before the operation. Your child will also need a nasogastric tube, which is passed up the nose, down the food-pipe and into the stomach. This will drain off the stomach and bowel contents and ‘vent’ any air that has built up, which will make your child more comfortable.

What does the operation involve?

The operation is called a Ladd procedure. The surgeon will straighten out the twisted bowel and separate any adhesions. If the bowel looks healthy, the surgeon will coil it back into the abdomen. Usually the surgeon will also remove the appendix during this operation, as it is often on the wrong side of the body in malrotation, which could cause problems in diagnosing appendicitis later in life. In a complicated condition the surgeon will remove any parts of the bowel where tissue has died. The amount can vary, but the surgeon will leave as much of the bowel as possible. If the surgeon has to remove a large part of the intestine, he or she may need to create an artificial way of disposing of waste matter, called a ‘stoma’.

Are there any risks?

All surgery carries a small risk of bleeding during or after the operation. Every anaesthetic carries a risk of complications, but this is very small. Your child’s anaesthetist is an experienced doctor who is trained to deal with any complications.

What happens afterwards?

For the first few days, your child will need to be fed through a tube into his or her veins so the stomach and bowel can start to heal. After a while, you can start to feed your child again, starting with small amounts, and increasing the amount as he or she tolerates it.

When you go home

The stitches used during the operation will dissolve on their own so there is no need to have them removed. If possible, keep the operation site clean and dry for two to three days to let the operation site heal properly. If your child needs to have a bath, do not soak the area until the operation site has settled down.

What is the outlook for children with malrotation and volvulus?

The outlook depends on how quickly the malrotation and volvulus are diagnosed as this in turn can influence the amount of damage to the bowel.

Meckel’s diverticulum is one of the most common congenital digestive system disorders – congenital means that the disorder was present at birth. When your child’s small intestine was developing, a small pouch formed consisting of tissue from elsewhere in the body. Usually the pouch – also known as Meckel’s diverticulum – is formed from tissue similar to that found in the pancreas or stomach. In many cases, Meckel’s diverticulum does not cause any problems. Up to two per cent of the population will have a Meckel’sdiverticulum.

What causes Meckel’s diverticulum?

We do not really know why this pouch forms during pregnancy. The intestines form early in pregnancy as a long straight tube – before the tenth week they grow and bend to develop into the separate organs making up the digestive system. The Meckel’s diverticulum occurs at this point of bending, and is a leftover bit of development.

What are the signs and symptoms of Meckel’s diverticulum?

Many people will be unaware that they have this pouch in their small intestine as it causes no problems at all. However, in a small proportion of children, the pouch releases acid like the stomach which over time can cause ulcers to develop in the small intestine. These can worsen and bleed which shows as large amount of painless blood in the stools. It can also leak the liquid inside the small intestine into the abdomen, leading to a serious infection called peritonitis. The pouch can also twist leading to a condition called volvulus. Twisting can cause the blood supply to the intestine to be cut off, which can be a life threatening condition. It can also fold inwards leading to a condition called intussusception. Symptoms of volvulus and intussusception can include sudden bouts of crying and pulling the legs into the body which then stop suddenly. As little or no food or liquid can pass the twisted or blocked portion, your child may also pass little or no faeces (stools). This causes cramps, as the bowel cannot push food and liquid past the twisted section of bowel. The twisting also cuts off the blood supply to the bowel, which can lead to the tissues in the bowel becoming inflamed and starting to die. Vomiting, especially green vomit is another symptom of volvulus and intussusception, as your child is unable to digest food as usual. If the condition is not treated, your child will become dehydrated which can be life threatening. The symptoms of dehydration may appear in phases and include lethargy, reduced urine output and dehydration.

How is Meckel’s diverticulum diagnosed?

If your child has a blockage an x-ray or ultrasound scan will be used to identify the affected part of the intestine. Sometimes a test called a Meckel’s scan is used to show your child’s intestine and whether it contains a certain type of tissue that can cause bleeding. The scan works by injecting a substance called an isotope into your child’s veins, which then travels through the blood supply to the intestine. A series of pictures are taken while the isotope is passing through the intestine. This scan may not always identify the pouch. Laparoscopy is diagnostic and therapeutic (curative) for Meckel’s diverticulum. This involves inserting a small telescope and camera inside your child’s abdomen. Meckel’s diverticulum may also be discovered incidentally during another procedure like an appendicectomy.

How is Meckel’s diverticulum treated?

If the Meckel’s diverticulum is causing problems, your child will need an operation to correct it. The Meckel’s diverticulum is cut at its base where it is attached to the small intestine and the defect is then closed with stiches. Some times if the base is very wide, 1 – 2 cm of the small intestine segment along with the Meckel’s diverticulum may be needed to be removed and the rest of the intestine reconnected with stiches.

What happens next?

Immediately after the operation, your child will be kept fasted so the stomach and bowel can start to heal. Once the bowel starts to work, the child can start to feed your child again, starting with small amounts, and increasing the amount as tolerated.

Outlook:

The outlook depends on how quickly the problem was diagnosed and treated as this in turn can influence the amount of damage to the bowel.


What is a nephrectomy?

A nephrectomy is an operation to remove a kidney. The child generally needs to stay in hospital for up to 2-3 days.

Why does my child need to have this operation?

Your child will need this operation because a kidney is not working properly. This could cause infections which may damage the other kidney, and makes it more likely that your child will have high blood pressure at some point in their life. Being left with one kidney should not cause your child any problems.

What does the operation involve?

The surgeon will remove your child's damaged kidney through a cut (incision) in his or her side. The operation takes between one to one-and-a-half hours. Nowadays, this operation can also be done with the help of laparoscopy of minimally invasive surgery. This involves three small 5 mm holes on the side of the child and the kidney is removed without any cuts. When done laparoscopically, the hospital stay and pain in reduced.

What happens after the operation?

Your child will be brought back to the ward to recover. He or she will be able to eat and drink soon after the operation.

Your child may have a tube (catheter) coming out of the bladder to drain away urine. This is usually removed two days after the operation and then you will be able to go home. Sutures are dissolvable and so you do not need to have them removed.

What are the risks of a nephrectomy?

All surgery carries a small risk of bleeding during or after the operation. After an anaesthetic some children may feel sick and vomit. They may have a headache, sore throat or feel dizzy. These side effects are usually short-lived and not severe.

Usually, there is only a small amount of bleeding, but occasionally a child may need to be given extra blood in the form of a transfusion.

When you get home

You should encourage, but not force, your child to drink.

The child may required pain relief medications if he has pain. The doctor will ask you to come for follow up examination a week after surgery.

Nose bleeds are when the small fragile blood vessels in the nose break. This will cause the nose to bleed. It is a common condition, especially in young children. Children who have frequent nosebleeds should be checked for underlying conditions by a doctor.

What causes nose bleeds?

Nosebleeds are pretty common, especially in young children. This is because the blood vessels in the nasal lining are close to the surface and quite fragile. They can rupture easily. A bump or bang on the nose can often result in a nosebleed. Young children often play very physical games, whether it’s rushing around on the playground at nursery or school or tumbling about at home. Bumps on the nose can be pretty common. If a child picks their nose or blows it too vigorously, this can also start a nosebleed. Sometimes even a violent sneeze can damage the nasal blood vessels, and trigger a nose bleed. While nosebleeds are rarely dangerous, very occasionally, a nosebleed can indicate a more serious underlying problem like a head injury.

What are the signs and symptoms of nose bleeds?

If a child has a nosebleed after suffering from a bump on the head, it’s important to look carefully for other signs that might indicate an underlying injury. If the child has any of the following symptoms emergency medical advice should be sought: • confusion • drowsiness • nausea and vomiting • losing fluid through their nose that is thin and watery

How are nose bleeds treated?

If a child has a nose bleed, the recommended course of action is: • Ask the child to sit down with their head tilted forward. • Get them to breathe through their mouth. • Put a bowl under the nose and give them tissues or a cloth. • Ask them to pinch the front, soft part of their nose for 10 minutes – or pinch it for them if it is a young child. • If tolerated, apply an ice pack to the affected area • After 10 minutes, release the pressure – if the bleeding has not stopped, reapply the pressure for up to two further periods of 10 minutes. • Once the bleeding stops gently clean the area. Do not tilt the child’s head backwards. This will not stop the bleeding and can cause blood to trickle down their throat. This can make them vomit or choke and affect their ability to breathe.

When to ask for medical help about nose bleeds ?

If the bleeding does not stop after 30 minutes, it’s best to take the child down to your local hospital or seek medical advise. Frequent nosebleeds Some children do seem more prone than others to frequent nosebleeds. If a child does seem to suffer from them more than twice a week, it’s advisable to see a doctor. It’s important in the first instance to rule out an underlying bleeding disorder.The doctor may recommend blood tests. Another more common explanation for frequent nosebleeds is that the child may have picked their nose causing blood vessels in the septum, the cartilage which divides the nostrils, to bleed. The doctor can also check for any signs of infection. If there is any infection, the doctor will probably prescribe a course of ointment with antibiotic and anti-inflammatory properties. A child who has a deviated septum is more likely to suffer from nosebleeds. A deviated septum means that the septum is slightly bent, usually as a result of injury (for instance a sports injury or an injury sustained during birth). The deviated septum causes abnormal airflow through the nose which causes the lining of the septum to dry out and bleed easily.

What happens next?

Most children, even those who suffer from frequent nosebleeds, tend to outgrow it. Nosebleeds can also happen in adult life but it is less common.


What is an Oesophagoscopy and Gastroscopy?

An oesophagoscopy and gastroscopy is a procedure that allows the doctor to look inside your child’s oesophagus (the tube which goes down into their stomach from their throat, also called the gullet or foodpipe), stomach and duodenum (where the stomach joins the small intestine). To do this test, an endoscope (a thin, flexible tube with a bright light at the end) is passed through your child’s mouth and down into their stomach. This is carried out under general anaesthetic and the procedure lasts for about 30 minutes.

An oesophagoscopy and gastroscopy allows the doctors to find out what is causing your child’s problems without performing a larger operation.

Your child may need an oesophagoscopy and gastroscopy if he or she is having trouble swallowing, persistent vomiting or has previously had an operation on the foodpipe that needs checking. Your child may need dilatation if he or she has a narrowed foodpipe due to scarring from previous operations or illnesses. This may also be needed to take out foreign bodies like coins, safety pins or any other foreign objects that your child may have accidentally swallowed. The procedure also allows the doctors to take a biopsy (small piece of tissue) if needed. This can then be examined closely in the laboratories.

This procedure may also be needed to stretch your child’s foodpipe if it is narrower than usual during the procedure. This is called oesophageal dilatation.

Are there any risks with an OGD?

There is a very small risk that your child’s foodpipe could become damaged while it is being stretched, but this depends on the amount your child’s foodpipe needs stretching. Where possible, the doctors will carry out the dilatation several times on separate occasions, rather than risk stretching the foodpipe too much.

Gastroscopic views of different parts of the oesophagus, stomach and duodenum What happens afterwards?

After the procedure, the doctor will remove the endoscope and give your child another type of medication to help them wake up. The child will remain sleepy after the procedure and this can last for two to four hours and during this time the child will be observed in hospital. Once your child is awake and sitting up on their own, they will be able to eat and drink.

What is oesophageal atresia?

Oesophageal atresia (OA) is a rare condition where a short section at the top of the oesophagus (gullet) is closed off. This means food cannot pass from the throat to the stomach.

What is tracheo-oesophageal fistula?

Tracheo-oesophageal fistula (TOF) is another rare condition, which tends to occur alongside oesophageal atresia. This is where the bottom end of the oesophagus is joined to the trachea (windpipe).

How are OA and TOF diagnosed?

Both OA and TOF tend to be diagnosed soon after birth. The doctor may try to pass a tube through the baby’s nose into the stomach (naso-gastric tube or NG tube), and find that it is not possible.

What causes them?

The causes of Oesophageal atresia are not known. It happens in 1 in 3000 to 1 in 5000 liver births. It is not due to anything that happened during pregnancy. OA and TOF can be associated with other problems like cardiac defects, bone or vertebral defects, anorectal malformations, kidney anomalies. All these will need to be looked for when a child is born with oesophageal atresia.

How are OA and TOF repaired? Are there any other options available?

This requires an operation. There are no other options or alternatives available for this.

What does the operation involve?

To repair the TOF, the surgeon will separate the oesophagus from the trachea and repair the part of the trachea where the oesophagus was originally joined. The method used to repair the OA depends on the distance between the ends of the oesophagus. In most cases, the surgeons will cut the blind end of the oesophagus and then join the two ends together to form a continuous passage from the throat to the stomach.

In rare cases called ‘long gap OA’ where the distance between the ends of the oesophagus are too large for the surgeon to be able to join them straightaway. Also in some children, the lower end of the oesophagus may not be connected with the trachea (pure oesophageal atresia without T.O.Fistula) . In these events a staged operation may be needed.

What happens afterwards?

The child comes back to the intensive care unit. The child may need help with breathing with either oxygen support or in some children with a ventilator. All babies are closely monitored after the operation. Your baby will be connected to monitors to check his or her breathing, heart rate and oxygen levels. He or she will also be given pain relief.

In a day or two, the child is started to be fed through the tube placed through the nose into the stomach. This continues for the next 5-7 days following which a study is done to show whether the repair has healed well. Following this, the child is fed milk orally. Once the doctors are happy that the child is feeding well, he or she is sent home. .

What is the outlook for children with OA and TOF?

If the OA and TOF occur on their own, with no other associated problems, the outlook for children who have them is good, with the majority growing up to live normal lives. The outlook for children with OA and TOF who have other difficulties varies depending on how severe these other problems are.

However, there are a couple of problems which may occur and which you should know about. They tend to happen most often in the first few years after the operation and improve as the child grows older. The area of the trachea which was attached to the lower end of the oesophagus may become floppy or lax. This is called tracheomalacia. This leads to a distinctive loud ‘barking’ cough which is many a times scary for the parents. However, this tends to improve with age and has little effect on the child’s breathing when older.

Feeding problems may also occur due to the oesophagus narrowing where it was originally repaired. Sometimes it needs widening and this will be done with the help of endoscopes.

Some children who have had OA and TOF develop a problem with gastro-oesophageal reflux when they are older. This is where the contents of the stomach flow back up the oesophagus (gullet) causing pain and irritation. This needs treatment in the form of medications and dietary modifications. Severe and long standing cases or children with associated complications secondary to the gastro-oesophageal reflux may need operative treatment also. The doctor would be explaining details of the same if and when required. More details can be obtained from the ‘gastro oesophageal reflux’ leaflet.

An ovarian cyst is a pocket of fluid that can develop on an ovary. Ovarian cysts are very common and can affect girls and women of any age. Ovarian cysts can appear as part of the way the ovary works normally. This type of cyst may not cause symptoms and does not usually need treatment. However, sometimes cysts can be quite large and cause other problems such as pain. If this happens then surgery may be required to remove the cyst. The majority of cysts in children and adolescents are benign (non-cancerous).

What causes an ovarian cyst?

The ovaries sit either side of the womb (uterus). Ovarian cysts occur when a pocket of fluid develops on the ovary. There are two main types of ovarian cyst - functional and pathological. Functional ovarian cysts are the cysts which develop as part of the way the normal ovary works. They are extremely common. They are harmless and usually disappear without treatment. They are always benign and often go unnoticed. However sometimes they can cause pain. This is usually because they twist or burst (rupture). Sometimes a small amount of bleeding can occur into the middle of the cyst. This is called a haemorrhagic cyst and can be painful. Pathological ovarian cysts are cysts which are not part of the way the ovary normally works. There are several different types of pathological cyst including dermoid cysts and cystademomas. These cysts can grow and become quite large. As they grow they can cause pain. In addition they can also twist or burst or bleed.The majority of these cysts are benign but very rarely they can be cancerous. Polycystic ovarian syndrome is when lots of small cysts form on the ovaries. They are caused by a hormonal imbalance and are harmless.

What are the signs and symptoms of an ovarian cyst?

    Most ovarian cysts do not present any symptoms. But some can cause symptoms, including:
  • sudden, sharp pain (which means the cyst may have burst)
  • dull, aching feeling (which means the cyst may be large)
  • bloated abdomen
  • irregular or heavy periods
  • frequent urination
  • nausea or vomiting

Any sudden, sharp or persistent pain could be a sign that the ovarian cyst has burst. This can be serious and medical attention may be needed immediately.

How is an ovarian cyst normally diagnosed?

As most ovarian cysts do not present any symptoms, they often go undiagnosed. They may be spotted by chance due to an unrelated condition. An ultrasound scan will confirm if a cyst is present and how big it is. The ultrasound scan will also be able to see what the inside of the cyst looks like. Most functional cysts are filled with fluid only. Sometimes evidence of bleeding (haemorrhage) into the cyst can be seen on scan. Pathological cysts are often a mixture of fluid and solid tissue. The scan can usually tell if there is a possibility that the cyst is cancerous. If there is a possibility that the cyst is cancerous, then more detailed tests such as a CT Scan or MRI scan may be suggested. In addition a special blood test will be taken to look for “tumour markers”. These are hormones in the blood which can be at higher levels in cancerous cysts.

How is an ovarian cyst normally treated?

Treatment will depend on the size of the cyst, the symptoms presented and what the cyst looks like on ultrasound. If the cyst is small and functional, then no treatment is needed. The cyst will go away on its own. A repeat scan is usually done in about six to eight weeks time to check the cyst has gone. If the cyst is large or is causing pain then it may need removing at an operation. The majority of ovarian cysts are removed with laparoscopy or keyhole surgery. This means inserting a small telescope through the abdomen and to look at the cyst and remove it. The recovery from this operation is usually very quick. In certain cases where the large cyst causes a torsion (twisting) or the ovary leading to gangrene (no blood supply) to the ovary. In such a scenario, the ovary along with the cyst will need to be removed. If there is any concern that the cyst is cancerous then the ovary will need removing. This is also often done with keyhole surgery however sometimes a small cut will need to be put over the lower abdomen.

What happens next?

If a cyst has been removed at an operation, then laboratory test are done on the cyst to check there are no cancer cells there. If the tests confirm a benign cyst only then no further follow-up is needed. These cysts also rarely affect fertility. If a cyst is confirmed as cancerous, then further treatment will be needed and the doctor would discuss this in more detail.


How does the urinary system work?

The urinary system consists of the kidneys, the bladder and ureters. The kidneys filter the blood to remove waste products and form urine. The urine flows from the kidneys down through the ureters to the bladder. Another tube called the urethra takes urine from the bladder to the outside.

What are posterior urethral valves?

Posterior urethral valves (or P.U.Valves for short) are a condition found only in boys. It affects the urethra (the tube which runs from the bladder to the outside). In boys with PUV, the urethra has a blockage in it near the bladder. This makes it difficult for the child to pass urine. As the bladder pushes hard to get the urine out, it causes pressure which may result in urine being pushed back from the bladder into the ureters and kidneys. This causes the kidneys and bladder to swell and may lead to kidney damage.

What are the symptoms of PUV?

There are various symptoms associated with PUV, but they may not affect every child in the same way. The degree of blockage affects the severity of the symptoms. Some symptoms include:

  • an enlarged bladder, so that it can be felt through the abdomen as a lump
  • urinary tract infections (UTIs)
  • difficulty in passing urine
  • a weak stream of urine, the child passes urine in drops
  • unusually frequent urination
  • poor weight gain
How is it diagnosed?

PUV can be diagnosed by a routine ultrasound scan during pregnancy if the bladder, ureters or kidneys are swollen. It can also be diagnosed in a newborn baby if the bladder is swollen and urine dribbles constantly. If the blockage was not severe before or just after birth, the condition can remain undetected until the child has symptoms as above.

The severity of the blockage affects how the condition is diagnosed. Each case will be different, but the following tests are usual:

Ultrasound of the abdomen - this is very similar to the ultrasound scan that most women have during pregnancy. It creates a picture of the organs inside your son’s body and shows how well they are working.

Micturating cystourethrogram (MCUG) - this test shows urine passing from the bladder to the urethra and then to the outside. It will also show if the urine is flowing backwards towards the ureters and kidneys (this is known as reflux).

Cystoscopy - this is a scan which uses a small tube with a camera at the end to examine the inside of the bladder.

Blood tests - these will show how well your child’s kidneys are working and check that there is enough fluid inside the body.

Other tests and scans may be needed to check that other parts of the urinary system are working properly. These can include kidney and bladder function tests.

What causes PUV?

It is not inherited in any recognized way and seems to happen in the early stages of pregnancy when the organs, muscle and other tissue starts to form. It is not due to anything you did or ate during pregnancy.

How rare is it and who is affected?

PUV seems to occur in one in every 8000 births and affects only boys.

How can PUV be treated?

There are several options for treatment, depending on how severely the symptoms are affecting your child:

  • The first course of action usually deals with the symptoms and includes putting a catheter (thin, plastic tube) into the bladder to drain away the urine. Any UTIs and fluid imbalance will also be treated with antibiotics and intravenous (IV) fluids, which are delivered directly into a vein.
  • Next course of action is to try to remove the parts of the valve which are causing the backflow of urine into the kidneys. This is usually carried out using a cystoscope (a tube with a light on the end) rather than a traditional ‘open’ operation.
What is the outlook for children with PUV?

The outlook depends on how much damage has already occurred in the kidneys. This depends upon the blood test results of the child. Children operated for posterior urethral valves will need long term and regular follow up to check that there is no lasting damage to the urinary system following the problem.

Pleural Effusion (Empyema) is a condition where pus collects in the pleural space (space outside the lung and inside the chest wall, often as a complication of pneumonia. The lungs and inside of the chest cavity have a smooth covering called the pleura that lets the lungs expand without rubbing on the inside of the chest. The two layers of pleura are usually in close contact with only a small space in between (pleural space) filled with a small amount of pleural fluid acting as lubrication. This complication of pneumonia usually occurs in three stages. Initially, clear fluid collects up in the pleural space which can then become infected. The fluid thickens and can affect the pleura, causing sections to ‘stick together’ eventually forming ’pockets’– this is called empyema. The infected fluid stops the lungs inflating completely, causing increasing breathing difficulties.

What causes empyema?

Empyema usually develops following pneumonia – various bacteria can cause pneumonia (most common ones are Staphylococcus pneumoniae and Staphylococcus aureus). Empyema seems to becoming more common, particularly in young children aged one to four years. It tends to occur during winter and spring season, when pneumonia and other chest infections are more common. Sometimes tuberculosis may also be a cause of empyema.

What are the signs and symptoms of empyema?

Empyema is usually suspected when a severe bout of pneumonia does not improve with treatment. Children usually show symptoms of being generally unwell with a high temperature. They may find breathing harder than normal, struggling to catch a breath. Their heart rate may also be higher than usual. Some children may describe pain in their chest when breathing.

How is empyema diagnosed?

If empyema is suspected, a chest x-ray may be the first test suggested to confirm or rule out the diagnosis. Chest x-rays will show white areas that suggest fluid. An ultrasound of the chest is more precise at showing the amount of fluid and the exact location and whether there are any pockets. In some cases, the doctor may also ask for a CT Scan of the chest to make sure that the child does not have any structural problems with the lung like a lung abscess which may have caused an empyema.

How is empyema treated?

Empyema previously used to be treated by placing a chest drain in the chest and with intravenous antibiotics as well as medicines to stop the pus clumping together. However, nowadays with the advance of minimally invasive surgery, Empyema is treated with VATS (Video assisted thoracoscopic surgery) wherein a telescope is inserted into the chest cavity and all the pus is removed under vision. The pus pockets are broken down and washed with antiseptic liquids and a chest drain is placed. The surgery is completed with 2 or 3 5 mm instruments rather than placing a big cut on the chest. Also as the procedure is done undervision, the doctor is sure that the pus has been completely cleared and the child also recovers early.

What happens next?

The outlook for children with empyema is usually good once it has been diagnosed and treated promptly. Long term lung damage is rare. With thoracoscopy, the recovery is just in a few days. Once the lung is completely expanded as seen on follow up x-ray, the chest tube is removed and the child is sent home on oral medications. They will also need regular follow up clinic appointments, usually involving a chest x-ray, to check that the pleura is healing properly without any problems.

There are a number of conditions that can affect the foreskin (the piece of skin covering the top of the penis). They can affect boys of all ages and are usually easily treated. The foreskin is the piece of skin that covers the top of the penis.

Conditions that can affect the foreskin include:

• Tight foreskin (Phimosis) – where the foreskin cannot be pulled back to reveal the head of the penis. All boys are born with phimosis. The foreskin retracts spontaneously by the age of 1 ½ to 2 years. A tight foreskin in puberty or adulthood can increase the risk of infection and cause problems with urination. • Paraphimosis – A condition where the foreskin has retracted but gets trapped, restricting blood flow to the head of the penis. The penis will turn dark purple. Paraphimosis requires immediate medical attention as this condition can cause permanent damage to the penis if not treated early. • Balanitis – an inflammation of the tip of the penis and foreskin usually caused by chemical irritation, bacterial or fungal infection. The head of the penis will become red, swollen and sore and there may be a thick and lumpy discharge.

What causes foreskin problems?

Foreskin problems can be the result of: • Poor personal hygiene (not cleaning the head of the penis correctly) • Infection • Forcible attempts to retract the foreskin What are the signs and symptoms of foreskin problems? The appearance of the foreskin is usually enough to see whether there is a problem.

How are foreskin problems diagnosed?

In the case of paraphimosis (where blood flow is restricted and the penis turns purple), you should visit the hospital immediately as this condition can cause permanent damage to the penis.

How are foreskin problems usually treated?

In the case of infection, a child may be given a course of antibiotics or a steroid cream to reduce inflammation and irritation. The course of treatment may last between two and four weeks, depending on the severity of the strain of infection. Some children may require a surgical procedure, such as: • Circumcision - where the foreskin is removed altogether. • Preputialplasty - where the opening of the penis is widened by an incision without removing the foreskin. The foreskin at the end of the operation would look just like a normal skin. All of these procedures are carried out under anesthetic

Can foreskin problems be prevented?

Good hygiene is key to preventing problems that can be caused by infection. In babies and children, the best way to clean the penis is by using water and baby soap. Don’t worry that you are not able to pull back the foreskin at this age – it’s very important not to try to retract a child’s foreskin forcibly, because this may cause damage to the delicate tissues of the penis. It could lead to bleeding, inflammation and the formation of scar tissue. Once the foreskin begins to retract, the glans will naturally become more visible and easier to clean. It is important to be gentle – the less scrubbing the better. When boys reach adolescence, they should be encouraged to retract and clean their foreskin regularly.

What happens next?

Once treated, a child should not experience any further discomfort and there should be no further impact on his health.

Pyloric stenosis is when the passage between the stomach and small bowel (pylorus) becomes narrower. The passage is made up of muscle, which seems to become thicker than usual, closing up the inside of the passage. This stops milk or food passing into the bowel to be digested.

What are the symptoms of pyloric stenosis?

Pyloric stenosis is commonly seen in the first born male child of the family. In most cases, a baby with pyloric stenosis is well until the age of 3-4 weeks following which the child will begin bringing up small amounts of milk after feeding. Over a few days this will become worse until the baby can no longer keep any milk down. This vomiting may become so forceful that the milk may be projected for several feet out of the baby’s mouth. This is called projectile vomiting. As the milk is lying in the acid in the stomach, it can curdle and become yellow in colour. This also reduces the amount of faeces (stool) passed, as little or no food is reaching the bowel. If the condition is not treated, the baby will become dehydrated and not gain weight. Signs of dehydration include lethargy, reduced urine output and the soft spot (fontanel) on the top of the head may be sunken.

What causes pyloric stenosis and how common is it?

Pyloric stenosis is a fairly common reason for babies needing an operation and usually develops around four to six weeks after birth. We do not know exactly why pyloric stenosis develops, but it tends to affect more boys than girls, and seems to run in families too.

How is pyloric stenosis diagnosed?

The thickened pyloric muscle can be felt, especially during feeding, as a small, hard lump on the right side of the baby’s stomach. The muscles around the stomach can sometimes be seen straining, moving from left to right as they try to push milk through the pylorus. Sometimes the doctors may want to confirm the diagnosis using tests and scans. These can include an ultrasound scan or even a contrast swallow and x-ray examination.

How is pyloric stenosis treated?

Pyloric stenosis is usually treated in an operation under general anaesthetic, lasting about 30 minutes. The operation is called a pyloromyotomy. Most are carried out using keyhole surgery (laparoscopically) but occasionally open surgery is suggested. The effects of pyloric stenosis, like dehydration due to the vomiting, can become serious quite quickly in children, and so there are no alternatives to the operation.

What happens before the operation?

If your child is dehydrated, he or she will need a ‘drip’ of fluids for a while before the operation. This will make sure that your child’s blood contains the right balance of salts and minerals, and treats the dehydration. Your child will have the operation once his or her blood test results are normal. They will also need a nasogastric tube, which is passed up the nose, down the food-pipe and into the stomach. This will drain off the stomach contents before the operation.

What does the operation involve?

The surgeon will cut through some of the thickened muscle, which widens the passage so that milk and food can pass into the bowel to be digested. If the operation was carried out using keyhole surgery, your child will have three small incisions in the abdomen, which will be closed with dissolvable stitches and skin glue. If your child has had open surgery, there will be a larger incision by the belly button, closed with dissolvable stitches,

What happens afterwards?

Your child will come back to the ward to recover. He or she will have been given pain relief during and after the operation. For the first few hours, your child will continue to have fluids through the drip so that the stomach and bowel can start to heal. After twelve hours or so, we will start to feed your child, starting with small amounts, and increasing the amount as he or she tolerates it. Your child may still have some vomiting but this will improve as the digestive system recovers from the operation. Your child will be able to go home once he or she is feeding well.

What is the outlook for children with pyloric stenosis?

Most pyloric stenosis operations are successful, with the immediate effect of reducing or stopping completely any vomiting after feeds.


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Kidney (or renal) stones are clusters of tiny crystals that can form in the kidneys. Most clusters are too small to cause any problems and pass out of the body in the urine. Sometimes, the clusters can clump together to form bigger clusters, which may eventually become big enough to block the filtering units in the kidney. Sometimes, they pass out of the kidney down the ureter and out in the urine without causing any problems, but if they are big they may block the ureter or lodge in the bladder. Kidney stones are much more common in adults than in children. Children who have kidney stones will be checked thoroughly to rule out or confirm an underlying condition causing the problem. This could include a structural abnormality with the urinary system or a problem with the metabolism.

What causes kidney stones?

The urinary system consists of the kidneys, ureters, the bladder and urethra. The kidneys filter the blood to remove waste products and produce urine. The urine flows from the kidneys down through the ureters to the bladder, where it is stored until we go to the toilet. It passes through another tube called the urethra to the outside when urinating. The kidneys contain millions of tiny filtering units called glomeruli. As blood passes through the tubes in the glomerulus, waste products pass through the walls of the tubes to form urine. Blood cells and other things such as protein cannot pass through the walls because they are too big. The urine contains lots of different substances, which do not cause any problems when the urine is weak and the amount of each substance is balanced. However, when the urine becomes too concentrated, often due to dehydration, the proportion of these substances in the urine increases, which can make crystals form. They can also form if the amount of these substances increases because the body is making more of them than it should or not removing them normally. In rare situations, kidney stones can develop after urinary infections. Some children are more at risk of kidney stones, for instance, children who were born prematurely or those who have very limited mobility, such as those confined to wheelchair..

What are the signs and symptoms of kidney stones?

Some kidney stones do not cause any symptoms at all, particularly if they are very small and not causing a blockage. However, kidney stones can be painful and cause blood in the urine (haematuria) and generally feelings of being unwell, such as a high temperature and vomiting. If the stone passes out of the kidney into the ureter, it can cause severe pain. Kidney stones can cause an infection. Signs of an infection include a high temperature, vomiting and/or diarrhoea and urine that is pink or cloudy. Studies have shown that pain is not experienced in approximately half of young children with stones.

How are kidney stones normally diagnosed?

Apart from the history which is derived from asking you questions about the problem, various imaging scans may be needed to confirm the diagnosis, see where the kidney stones are located and their size. Anultrasound scan is usually the first test to help make the diagnosis, although other scans may be needed as well. Urine tests will be needed to show whether there is an infection and to measure the chemicals that cause stones. Blood tests will show how well the kidneys are working.

How are kidney stones normally treated?

This depends on their size and location. Smaller stones can be broken up using sound waves (lithotripsy). Some stones that are stuck in the ureter can be removed using an endoscope, a tube containing a small camera, a light and a laser device to break up the stone. Most other stones are removed using surgery through a small cut. The final decision as to how to remove the stone will vary from child to child and the number and size of stone and whether there are other problems related to the kidney or its drainage system that has caused the stone to form. Children with lots of stones or stones in both kidneys usually need several procedures to clear the stones. It is important to drink plenty of fluids to stop them forming again. Some children may need to reduce their salt intake and, rarely, other medicines or measures may be necessary.

A skull fracture is when bone in the skull has been broken by an injury or trauma. As the skull is very strong, it takes a lot of force to damage it. This might be from falling from a height, a car accident or a direct blow to the head.

What causes a skull fracture?

A skull fracture is caused by an injury or trauma to the head. A child may have fallen from a height, such as in a playground, and hit their head. Most skull fractures in children are caused when children are playing. Anyone can get a skull fracture. There are four main types of skull fracture:

  • Linear fractures are the most common. They are generally straight-forward breaks in the skull.
  • Depressed fractures are where the skull has been pushed in. Surgery may be needed to lift the bone if it is putting pressure on the brain.
  • Diastatic fractures are when a break occurs in more than one of the bones in the skull that are connected together. This causes the join to widen. This is usually found in young children because the bones in the skull have not fused together properly yet.
  • Basilar fractures are the most uncommon and appear at the base of the skull and can risk damage to the spinal cord.
What are the signs and symptoms of a skull fracture?

    If a child has hit their head, signs of a fracture include:

  • a lump or dent on the head
  • bruising or swelling on the head
  • headache
  • confusion or disorientation
  • dizziness
  • nausea or vomiting
  • loss of consciousness
  • clear fluid or blood running from the nose or ears
  • bruising around the eyes (panda eyes)
How is a skull fracture normally diagnosed?

If a child has hit their head it is vital they are checked by a doctor. A head injury or skull fracture can be very serious, even if the child initially seems fine. As the skull protects the brain, a skull fracture can also cause a brain injury. An x-ray will check for broken bones or fractures in the skull. A CT Scan looks inside the body to check the child’s brain for any signs of injury.

How is a skull fracture normally treated?

Treatment will depend on the type of skull fracture the child has and how severe it is. It can take months for a skull fracture to heal, but the younger the child is, the faster it will heal. If the child has an open wound on their head, it will need to be cleaned to avoid infection. Medicine can be given to treat the symptoms, such as nausea and pain. Surgery may be needed for a serious fracture if the bones have moved or if there are any fragments.

What happens next?

It is vital that all head injuries should be checked out at hospital. Most children with a simple, straightforward fracture will make a full recovery. More serious skull fractures will require treatment and maybe surgery

The intestines form early in pregnancy as a long straight tube. Before the tenth week of pregnancy, they develop into the separate organs making up the digestive system. Occasionally, the intestines are not completely connected or blocked (atresia). Sometimes there is a partial blockage (web) inside the intestine. Any part of the intestines can be affected by atresia or stenosis. Duodenal Atresia is one type. This occurs in around one in 6,000 births where the duodenum is closed off rather than being a tube. If the jejunum or ileum are affected, this is called ‘small bowel atresia’. Small bowel atresia is more common than duodenal atresia. We do not know how exactly how many babies are born with small bowel atresia each year but we do know that it affects boys and girls equally. It is more common in twins or multiple births and babies born prematurely or with low birthweight. Colonic atresia, affecting the large bowel, is very rare. Small bowel atresia affects two areas of the small bowel – the jejunum and the ileum. The jejunum is the section of small bowel after the duodenum and is where the majority of nutrients are absorbed. The ileum is the main part of the small bowel, making up over half of its entire length, and connects to the large bowel. The blockage can affect any part of the ileum or jejunum.

What causes small bowel atresia?

More research is needed into the causes of small bowel atresia but currently doctors think that it is caused by reduced blood supply to sections of the bowel as the baby is developing in the womb. It is unlikely that it is caused by anything you did or did not do during pregnancy.

What are the signs and symptoms of small bowel atresia?

Many babies born with small bowel atresia appear well at birth but when they start to feed, they start to have nausea and vomiting and their vomit may be green. Their abdomen may appear swollen but soft and their skin may develop a yellow tinge (jaundice). All newborn babies have meconium in their bowel. This is the dark green stool passed in the first day of life. Babies born with small bowel atresia may not pass any meconium at all or only a small amount. Not passing meconium does not prove that a baby has small bowel atresia but it may suggest it. Some babies with small bowel atresia pass meconium as expected.

How is small bowel atresia diagnosed?

When a baby with small bowel atresia is developing in the womb, they are may be surrounded by much more amniotic fluid than usual (polyhydramnios). Small bowel atresia can sometimes be suggested during pregnancy using an ultrasound scan. After the baby is born, small bowel atresia is usually diagnosed when there are signs of an obstruction, such as vomiting, green bile and a swollen abdomen. An x-ray scan may show a blockage. Occasionally, doctors may suggest using a contrast scan and/or enema instead or as well as an x-ray. Contrast scans and enemas use a thick, white liquid called barium or a clear liquid (contrast), both of which show up well on x-rays. The contrast cannot pass through the atresia suggests that atresia can be a cause.

How can small bowel atresia be treated?

Small bowel atresia is repaired in an operation under general anaesthetic. The operation to repair the atresia can is usually carried out using open surgery. Sometimes a laparoscopic surgery (key hole procedure) may help diagnose the problem so that it can be repaired using open surgery.

Are there any alternatives?

No. Small bowel atresia always requires surgical treatment to allow your baby to feed.

What happens before the operation?

Your baby will be transferred to the hospital soon after birth. If your child is dehydrated, they will need a ‘drip’ of fluids for a while before the operation. Your child will also need a nasogastric tube, which is passed up the nose, down the foodpipe and into the stomach. This will drain off the stomach and bowel contents and ‘vent’ any air that has built up, which will make your child more comfortable. When your child is stable, the surgeon will explain about the operation in more detail. Sometimes the atresia is suspected but may not be the only possible cause of the blockage. The surgeon will explain this to you.

What does the operation involve?

The surgeon will look at the bowel to determine the level of the blockage. If it is an atresia, this section is removed and the cut ends are joined together (anastomosis). This provides a clear passage for food and fluid to travel through your child’s intestine. The remainder of the small intestine will be checked for further atresias and treated if identified. If it is not possible or safe to join the two ends together during the same procedure, the surgeon may bring the end of the intestine to an artificial opening (stoma) in the abdomen to form an ileostomy.

Are there any risks?

All surgery carries a small risk of bleeding during or after the operation. There is a chance that the area where the two ends of bowel were joined could start to leak, allowing bowel contents to escape into the abdomen. This is usually treated with antibiotics, but a second operation may be needed to check the leaking portion. All abdominal surgery carries the risk of strictures forming. These are areas of scar tissue that can narrow the intestines, leading to obstruction. If your child vomits green bile and has a swollen abdomen, they should be reviewed urgently by a doctor. It can take a while after the operation for the bowel to start working properly so your child may need to be fed intravenously using total parenteral nutrition (TPN) for a while. This affects many children.

What happens after the operation?

While your child’s intestines recover and start to work, they may be fed through a tube into their veins (total parenteral nutrition or TPN). This will gradually be replaced by breast or bottled milk, given through the naso-gastric tube when your child is able to tolerate this. As your baby recovers, you will be able to feed them from the breast or bottle. Over time, the drips and monitors will be removed one by one.Most children stay in hospital for one to two weeks, but occasionally a longer stay is needed.

What happens next?

The outlook depends on the amount of damage to the bowel. Adhesions can form after any abdominal surgery and can cause further problems such as blockage or pain. This however is quite rare and may sometimes require another operation to separate the adhesions.

Syndactyly means 'joined digits' and may involve webbing of the skin, or include fusion of the underlying bones. This may be along part or the whole length of the finger. It is the second most common congenital hand problem and occurs in around 1 in 1000 births. Hand development occurs in the early stages of pregnancy and the fingers separate in the ninth week. Syndactyly happens when two or more fingers fail to completely separate during development. Sometimes syndactyly occurs by chance or it may be inherited. In rare circumstances, it may occur along with other signs as part of a syndrome (collection of signs). Syndactyly can occur unilaterally (on one hand only) or bilaterally (affecting both hands), and can affect two or more fingers. Occasionally it may be associated with extra digits or other abnormalities in the hands. Syndactyly can also affect the toes, involving webbing of the skin or fusion of the underlying bones along part or the whole length of the toe.

How is syndactyly treated?

It is treated surgically under a general anaesthetic. Surgery is usually only possible to one side of a finger at a time, as any damage to the blood supply on both sides could result in the loss of the finger. So, if your child has syndactyly of three or more digits next to each other, they will need more than one operation. Are there any alternatives to surgery? Surgery is the only option to separate the digits. The aim of the operation is to improve function (how well your child can use their hand) and sometimes appearance (how your child’s hand looks). Occasionally, some children could manage without treatment. Correction of toe syndactyly is usually for cosmetic rather than functional reasons.

What does the operation involve?

The surgeon will recreate a new web with local flaps of skin from the sides of the digits. This usually involves making a series of zig-zag incisions along the digits, and wrapping the zig-zag pieces of skin to cover up the inside surface of the digits where they were previously joined. In most cases, the surgeon will need to use a skin graft to cover up any gaps. This will be a different colour on the hand than the rest of the skin. Occasionally, a skin graft will not be needed.

Are there any risks?

There is a risk of infection as the skin is opened, but your child will be given antibiotics to reduce the risk of this. If an infection does occur, it is usually minor and easily treated with a course of antibiotics.There is a chance that the skin graft will not ‘take’, but looking after it carefully will help the operation site to heal as well as possible. Any infection or graft loss may affect the time the wounds take to heal and therefore the resulting scars. The amount of scarring varies from child to child. If your child tends to scar easily from cuts and grazes, it is likely that they will have noticeable scars after the operation, but these will fade in time.

What happens after the operation?

Their hand or foot will be covered in a large bandage to protect the skin grafts while they heal. Your child will soon find a way to use their bandaged hand or foot in everyday activities. It is best to keep the limb operated on raised above the level of the heart as much as possible to reduce any swelling, which in turn reduces any pain.It also minimises any oozing under the flaps and skin grafts. Your child’s limb may be raised using pillows or soft toys, or the hand may be placed in a sling when sitting or walking around.If your child’s fingertips or toes are visible, check them on a regular basis for warmth, colour, sensation, movement and blood flow. These checks show that the blood is flowing properly.

What is the outlook for children with syndactyly?

This depends on the degree of syndactyly and whether it occurred by chance or as part of a syndrome. The outlook for children with simple syndactyly is usually excellent. If the syndactyly occurred as part of a syndrome, the outlook depends on the particular syndrome and associated features.


The tonsils are areas of tissue on both sides of the throat, at the back of the mouth. Your child's tonsils help them to build up immunity and fight infection. In many children, the tonsils become repeatedly infected with bacteria and viruses, which make them swell and become painful. This is called tonsillitis.

What causes tonsillitis?

Tonsillitis is the word used when the tonsils are infected so swell and become painful. Both bacteria and viruses can cause an infection – these are usually picked up as part of everyday life so there is little you can do to prevent them although good hygiene including hand washing is important.

What are the signs and symptoms of tonsillitis?

The main symptom of tonsillitis is a sore throat, which is particularly painful when swallowing. Your child may complain of earache as well. The tonsils may also have a white covering or spots, which are a sign that the body is fighting off the infection. Your child’s neck may look a little swollen as well, and they may have a temperature.

How is tonsillitis diagnosed?

Tonsillitis can be diagnosed by looking closely in the mouth, sometimes using a small torch to look at the back of the mouth.

How is tonsillitis treated?

Pain relief medicines, such as paracetamol and ibuprofen can help reduce the pain and also bring down a temperature. If the infection was caused by a bacteria, the child will require antibiotics. Most cases of tonsillitis disappear within a few days. If your child has repeated bouts of tonsillitis, we may suggest an operation to remove the tonsils.

SURGERY FOR TONSILLS AND ADENOIDS

The tonsils and adenoids are areas of tissue at the back of the throat. The tonsils are on both sides of the throat, at the back of the mouth, and are clearly visible. Adenoids are not visible, as they are high in the throat behind the nose. Your child's tonsils and adenoids help him or her to build up immunity and fight infection. Adenoids and tonsils seem to grow during childhood and then shrink around the age of four. By the time your child reaches adulthood, his or her adenoids and tonsils will have disappeared almost completely. This is because they are no longer needed, as your child's body will have other defence mechanisms to fight against infection.

Why do tonsils have to be removed?

In many children, the tonsils become repeatedly infected with bacteria and viruses, which make them swell and become painful. Removing your child's tonsils and adenoids will solve these problems. Your child may have larger than average tonsils and adenoids, which partially block his or her airway. This can make it difficult for them to breathe through their nose. As a result, your child may breathe through their mouth and snore loudly when asleep. This can lead to a condition called sleep apnoea, where your child stops breathing for a couple of seconds while asleep and then starts again. This can severely disturb their sleep. There is also a link between large tonsils and adenoids and a condition called glue ear. This happens when the middle ear becomes blocked by a sticky substance which affects your child's hearing.

What are the risks of this operation?

Every operation carries some risk of infection but we will often give your child antibiotics as a precaution. The risk of bleeding is usually greatest in the first few days after this operation. It is rarely serious.

Are there any alternatives to this operation?

If your child is having difficulties in breathing or has developed glue ear, it is probably better to have his or her tonsils and adenoids removed.

When your child gets home

Your child will probably feel uncomfortable for a week after the operation and may find swallowing difficult. They may also be reluctant to eat certain foods or brush their teeth.

Eating and drinking

It will be tempting to give your child soft foods, but they should start eating normally as soon as they can after the operation. Even if your child is not eating a great deal, it is very important for them to drink lots of fluids. They may find it easiest to drink chilled liquid, but avoid acidic drinks, like orange juice, which will sting.

Brushing teeth

Brushing the teeth will help keep the mouth free of infection and enable the sore areas to heal more quickly. It will also freshen your child's mouth, especially if he or she is not eating a great deal.

School and activities

Your child should not go to school or nursery for 7-10 days after they leave hospital. Once they are feeling better, there is no restriction on what they can do.

Coughs and colds

Your child should try to avoid crowded places, where they might pick up infections, and people with coughs and colds, for two weeks after the operation.


What is the ureteric re-implantation operation and why might my child need it?

As shown in the diagram, the ureters are two tubes which carry urine from the kidneys to the bladder. In some children, the ureters do not join the bladder in the correct place and this can cause a condition called vesicoureteral reflux (VUR). Normally, valves between the ureters and the bladder prevent urine ‘backing up’ and flowing towards the kidneys. If the ureters do not join the bladder in the correct place, these valves can fail, allowing urine to flow backwards from bladder to kidney. This can damage the kidney and eventually lead to kidney failure.

What does the operation involve?

At surgery, an incision (cut) is made in the lower abdomen. The ureters are disconnected from their attachment to the bladder. The ureters are then reattached to the bladder in the correct place. The end of the ureters joining the bladder will then be surrounded by muscle, which will strengthen the valves, reducing the chances of urine flowing back to the kidneys. The operation takes between 1and a half and 2 hours. The usual hospital stay is 5 – 7 days.

What are the risks of this operation?

The operation risk is minimum. There is sometimes bleeding when the surgeon disconnects the ureters during the operation. This is usually only slight, but if a lot of blood is lost your child may need to be given a blood transfusion.

Are there any alternatives to the operation?

If your child has VUR and needs their valve to be repaired, there is one alternative to surgery. STING is an injection which is given into the valve in the bladder, with the help of cystoscopy (a tube with a camera on the end which is inserted into the bladder). STING is quicker and enables an early discharge from the hospital. More details about the pros and cons and whether your child is suitable for the treatment can be obtained at the time of consultation.

When you get home

The child should be encouraged to drink lots of water / liquids. Antibiotics will be given to your child at discharge to be continued for 6 weeks. A regular urine check needs to be done on a monthly basis for 6 months after surgery. We will monitor the postoperative changes with an ultrasound scan and if needed a nuclear scan. Advise regarding the same will be given to you at the time of discharge.

What are undescended testicles?

This is when the child’s testicles are not in their usual place in the scrotum. While your child is in the womb, the testicles are developing inside his abdomen. Towards the end of pregnancy, the testicles travel through a passage into the scrotum. Both testicles should be in the scrotum by the time the child is one year old. Generally, only one of the testicles is affected, but on rare occasions, both testicles fail to travel to the scrotum.

In some children, the testicles may be in the scrotum for much of the time but cannot be felt there because they naturally rise back into the body through fear or cold temperatures. This is called retractile testis. You can usually find this out by putting your child in a warm bath and checking whether you can feel both testicles. If this is the case, there is no cause for concern.

What are the symptoms of undescended testicles?

Usually, there will not be any symptoms at all, other than not being able to feel the testicles in the scrotum. Your child will not be in pain, and the undescended testicles will not interfere with any bodily function.

However, if one of the testicles becomes twisted (testicular torsion), this will be painful, either in the groin area or the abdomen, depending on the location of the testicle at the time.

How are undescended testicles diagnosed?

The doctor will need to determine whether the testicles are truly undescended or whether they have slid back into the body temporarily. This is usually done by feeling the abdomen and the scrotum. No investigations like ultrasound scan or CT Scan or MRI can determine the presence / absence or exact location of the testis. These investigations should be sparingly used for determination of the site of an undescended testicle.

What causes them?

On rare occasions, the testicle does not descend due to other problems with the testicles themselves or with the male hormones. We do not know exactly why this happens, but it is not due to anything that happened during pregnancy.

How common are they?

This condition is more common in premature babies. 33 % of premature and 3 % of term children are born with undescended testis. The incidence of undescended testis at the age of 1 year is 1 %. Hence only 2 % of testicles descend up to the age of 1 year. The incidence of undescended testis in the adult population is 0.8%. These figures show that after the age of 1 year, there is hardly any decrease in the incidence of undescended testis.

How undescended testicles are treated and are there any alternatives?

The method of treatment depends on the suspected cause. However, whatever the cause, undescended testicles are best treated in early childhood latest by the first birthday of the child. Your child’s testicles will need treatment as they do not seem to mature properly if left in the abdomen. The amount of sperm and fertility levels seem lower in men who have had undescended testicles, and even lower if they were not treated early in childhood. This is because the testicles need to be a few degrees cooler than the rest of the body to produce sperm. It is also impossible for men with undescended testicles to check for testicular cancer, as the testicles cannot be felt in the abdomen. If the testicles remain in the abdomen, this also increases the risk of testicular torsion.

What is an orchidopexy?

This is an operation to bring the testicles down from the abdomen to their usual place in the scrotum. This is a short operation under general anaesthetic, lasting about 45 minutes. Occasionally, a child will need to stay in hospital overnight.

What does the operation involve?

Operation involves moving the testicle down into the scrotum, and close up the passage through which the testicle should have travelled, to stop the testicle moving back into your child’s abdomen. The testis is secured in the scrotum to ensure that it remains in place and develops in the normal way. Operation can be done by the traditional open technique when the testis is palpable in the groins i.e. it has come out of the abdomen but not reached the scrotum. In cases where the testis has failed to come out of the abdomen key hole surgery or laparoscopy is used to determine the exact location of the testis in the abdomen along the course of its descent.

What happens afterwards?

The child will be reviewed a week after surgery. Follow up visits would be scheduled after 3, 6 and 12 months respectively.

What is the outlook for children with undescended testicles?

When the undescended testicles are treated in early childhood, the outlook is good. Your child will have normal fertility levels unless there were problems with the testicles themselves. In the event of the undescended testis being damaged prior to your realizing it / procuring treatment for the same, the child is left with on testicle. This however, should not affect your child’s fertility levels in later life to any great degree.

    Operative videos of laparoscopy in undescended testis:

  • Low Intra abdominal testis
  • High Intra abdominal testis
  • Pelvic testis
  • Atrophic testis
Urinary tract infections in children with abnormal urinary tracts

It is an infection affecting one of the various parts of the urinary system. Doctors often call it a urinary tract infection or UTI for short. The urinary system consists of the kidneys, ureters, the bladder and urethra. The kidneys filter the blood to remove waste products and produce urine. The urine flows from the kidneys down through the ureters to the bladder, where it is stored until we go to the toilet. It passes through another tube called the urethra to the outside when urinating (passing urine).

What is different about UTI in children with known problems with the urinary tract?

Some children are born with a problem with the urinary tract. There can be different malformations, such as posterior urethral valves, hydronephsosis and hydrometers or vesico-ureteric reflux. All these malformations have one thing in common, that is, the urine flow is not normal. It can be slow due to an obstruction or narrowing of the ureter for instance. There can also be ‘residual urine’, which means that the bladder is not emptied totally when passing urine, leaving some urine behind. These problems increase the risk of developing a UTI. A UTI has more impact on children with a known problem with the urinary tract, as they have kidney problems present from birth (congenital). If this is the case with both kidneys, or the child only has one kidney, then there is a risk that he or she has impaired kidney function.

What kinds of UTI are there?

There are three kinds of UTI, each with different symptoms, but all of which can be very important for a child with a known problem with the urinary tract.

Acute pyelonephritis

This means ‘infection of the kidneys’. This is the most important infection as it can cause kidney damage. It is therefore very important to diagnose and treat pyelonephritis rapidly. The main sign of a kidney infection is a very high temperature. A child will also have symptoms of being generally unwell, such as vomiting, drowsiness or pain affecting the stomach or sides. If your child develops an unexplained fever or any of these symptoms, you should always make sure that his or her urine is tested for infection. If there are signs of infection, the doctor will prescribe a course of antibiotics, which can prevent kidney damage. You should always ensure that your child completes the course of antibiotics, even if he or she seems to be getting better. If your child does not complete the course of antibiotics, then this could allow the infection to come back and possibly not respond so well to antibiotics the next time.

Acute cystitis

This means ‘infection of the bladder’. This often gives a lot of pain in the stomach and discomfort when passing urine. The urine can also contain blood and so look a red or pink colour. Generally, a child with a bladder infection will not have as high a temperature as a kidney infection. The infection needs treatment to take away the pain but it does not cause kidney damage.

Asymptomatic bacteriuria (ABU)

This means that bacteria is growing in the urine but is not producing any symptoms. Children with normal urinary tracts sometimes get ABU and it is very common in children any kind of problem with urine flow. It is not dangerous as it does not have any symptoms and does not lead to kidney damage. It is also very difficult to treat. Even if antibiotics treat the bacteria, it will often come back after a few days. Treatment with antibiotics is therefore reserved for when symptoms are present.

How can UTI be investigated?

The doctor will advise you depending upon the child’s age and symptoms as to what investigations need to be done. A urine routine examination will necessary and a urine culture will also be required to see what germs are growing in the urine and what antibiotics are effective against those germs. An ultrasound scan may be required to see if there is any structural problem with the urinary tract like blockage or abnormal swelling of the kidneys, ureters or the bladder. In some children an investigation called MCUG / VCUG (micturating / voiding cystourethrogram) may be required. In some children advanced investigations like a CT scan or a nuclear scan may also be required. Your doctor will explain you about the investigations and their need if required for your child.

How can recurrent UTI be treated?

The most important thing is to create a good flow of urine. Encouraging drinking of plenty of fluids combined with regular urination and avoidance of constipation are extremely important ways of preventing infections. This might mean an operation to remove any obstruction.. Remember

  • Children with known urinary tract problems are very prone to developing urinary tract infections (UTI).
  • Only some types of UTI cause kidney damage, and these normally cause a very high temperature and symptoms of being generally unwell.
  • These types of UTI need to be diagnosed and treated as early as possible to prevent kidney damage.
  • If your child has a very high temperature or is generally unwell with no obvious cause, ask your doctor to test your child’s urine.


Vesicoureteric Reflux

The urinary system consists of the kidneys, the bladder and ureters. The kidneys filter the blood to remove waste products and form urine. The urine flows from the kidneys down through the ureters to the bladder in a one way direction.

The ureters tunnel through the wall of the bladder at an angle to form a flap that acts as a valve. The valves between the ureters and bladder prevent urine flowing backwards into the ureters, so that all the urine in the bladder is passed in one go, as the urine cannot travel anywhere else. As the urine leaves the bladder at a high pressure, the valves stop this high pressure being passed on to the kidneys.

What is vesico-ureteric reflux (VUR)?

Vesico-ureteric reflux (VUR) occurs when the valve between the ureters and the bladder is not working properly, allowing urine to flow backwards into the ureters. Depending on the severity of the VUR, sometimes the urine can flow backwards as far as the kidneys. If infected urine flows into the kidneys, this can damage them.

What are the symptoms of VUR?

Sometimes VUR can be diagnosed before birth when an ultrasound scan shows that one or both of a baby’s kidneys look swollen and larger than usual (hydronephrosis). VUR is one of the conditions that cause hydronephrosis.

When VUR is diagnosed after birth, it is usually suspected if a child has repeated urine infections. Symptoms of a urine infection can include: burning sensation during urination, urinating more often than usual, abdominal pain, a high temperature, vomiting, reduced appetite or foul smelling urine. Some children also present with recurrent diarrohea or with poor weight gain. If a child has VUR, urine infections can damage the kidneys, as the urine flowing backwards towards them contains bacteria. Kidney damage can cause high blood pressure in later life or if untreated, may lead to kidney failure.

How is VUR diagnosed?

VUR is diagnosed and monitored using two particular scans:

• Ultrasound scans are used to diagnose hydronephrosis before birth and to check the structure of the bladder, ureters and kidneys after birth. • The other test is called a micturating / voiding cysto-urethrogram (MCUG / VCUG). This uses a liquid that shows up on x-rays, which is put inside the bladder through a catheter (thin, plastic tube) inserted into the urethra. Once the bladder is full of this liquid, the child urinates while being scanned. This shows whether all the liquid is being passed through the urethra, or whether any of it is flowing backwards through the ureters towards the kidneys. The MCUG / VCUG test is also used to ‘grade’ the degree of reflux, according to its severity; grade 1 is the least severe form of VUR, where urine is flowing back up the ureters but is not reaching the kidneys and grade 5 is the most severe, where a great deal of urine is reaching the kidneys, making the ureter and kidney swollen. VUR is also described as ‘unilateral’ or ‘bilateral’ depending on whether one kidney (unilateral) is affected or both (bilateral).

What causes VUR?

In many children, the tunnel through the bladder wall is not long enough, so the valve does not work properly, but this can improve as the child grows. In some children, the ureters enter the bladder in a higher position than normal, which also means that the valve does not work properly; this is less likely to improve as the child grows. Other children, particularly boys, may have a blockage in the urethra (posterior urethral valves) causing VUR.

How common is VUR?

VUR occurs in about one in every 100 children. If one child in a family has VUR, there is a chance that the other children could have VUR too, so monitoring might be suggested for brothers and sisters. VUR is usually diagnosed in under fives; it is much less common in older children, who may have outgrown the problem.

How can VUR be treated?

We treat VUR using medicines at first. Usually, a low dose of antibiotics is given on a long-term basis. This prevents urinary tract infections, which in turn, prevents any damage to the kidney caused by infected urine flowing backwards into them. Treatment with antibiotics gives many children the opportunity to outgrow VUR.

Children with VUR who are taking antibiotics will need to give regular urine samples, to be checked for any urine infections, particularly at an early stage. Ultrasound scans are often used to check that the kidneys are growing properly. Nuclear scans also are done to see how much damage is caused to the kidneys by the reflux.

Children who continue to have urinary tract infections despite the antibiotics, or still have severe reflux after the age of five years old might need an operation to correct the problem causing VUR. In this operation, called ureteric reimplantation, the ureters are disconnected from the bladder and re-attached at an angle to create a valve. Now a day, this surgery can also be done endoscopically.

Consequences of VUR?

Untreated VUR may lead to problems like poor weight gain, poor appetite, urinary tract infections and late onset hypertension or end stage renal failure.


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