Surgical Conditions

Whether you’re expecting a baby boy or have just welcomed your new little guy into the world, you have an important decision to make before you take your son home: whether to circumcise him.

For some families, the choice is simple because it’s based on cultural or religious beliefs. But for others, the right option isn’t as clear. Before you make a circumcision decision, it’s important to talk to your doctor and consider some of the issues.

About Circumcision

Boys are born with a hood of skin, called the foreskin, covering the head (also called the glans) of the penis. In circumcision, the foreskin is surgically removed, exposing the end of the penis.

Approximately 55% to 65% of all newborn boys are circumcised in the United States each year, though this rate varies by region (western states have the lowest rates and the north central region has the highest). The procedure is much more widespread in the United States, Canada, Africa, and the Middle East than in Asia, South America, Central America, and most of Europe, where it’s uncommon.

Parents who choose circumcision often do so based on religious beliefs, concerns about hygiene, or cultural or social reasons, such as the wish to have their son look like other men in the family.

Routine circumcision is usually performed during the first 10 days (often within the first 48 hours), either in the hospital or, for some religious ritual circumcisions, at home.

If you decide to have your son circumcised at the hospital, your pediatrician, family doctor, or obstetrician will perform the procedure before you bring your baby home. The doctor can tell you about the procedure and the possible risks. Circumcision after the newborn period can be a more complicated procedure and usually requires general anesthesia.

In some instances, doctors may decide to delay the procedure or forgo it altogether. Premature babies or those who have special medical concerns may not be circumcised until they’re ready to leave the hospital. And babies born with physical abnormalities of the penis that need to be corrected surgically often aren’t circumcised at all because the foreskin may eventually be used as part of a reconstructive operation.

The Pros and Cons

On the plus side, circumcised infants are less likely to develop urinary tract infections (UTIs), especially in the first year of life. UTIs are about 10 times more common in uncircumcised males than circumcised infants. However, even with this increased risk of UTI, only 1% or less of uncircumcised males will be affected.

Circumcised men also might be at lower risk for penile cancer, although the disease is rare in both circumcised and uncircumcised males. Some studies indicate that the procedure might offer an additional line of defense against sexually transmitted diseases (STDs) like HIV in heterosexual men. For HIV in particular, the findings come from studies done on populations of African men, and some experts feel that these data might not be as relevant to men in other areas of the world, like the United States.

Penile problems, such as irritation, inflammation, and infection, are more common in uncircumcised males. It’s easier to keep a circumcised penis clean, although uncircumcised boys can learn how to clean beneath the foreskin once they’re older.

Some people claim that circumcision lessens the sensitivity of the tip of the penis, decreasing sexual pleasure later in life. But none of these subjective findings are conclusive.

Although circumcision appears to have some medical benefits, it also carries potential risks — as does any surgical procedure. These risks are small, but you should be aware of both the possible advantages and the problems before you make your decision. Complications of newborn circumcision are uncommon, occurring in between 0.2% to 2% of cases. Of these, the most frequent are minor bleeding and local infection, both of which can be easily treated by your doctor.

One of the hardest parts of the decision to circumcise is accepting that the procedure can be painful. In the past, it wasn’t common to provide pain relief. But the American Academy of Pediatrics (AAP) recommends it and studies show that infants undergoing circumcision benefit from anesthesia, so most doctors now use it. But because this is a fairly new standard of care, it’s important to ask your doctor ahead of time what, if any, pain relief your son will receive.

Two main types of local anesthetic are used to make the operation less painful for a baby:

1. a topical cream (a cream put on the penis) that requires at least 20 to 40 minutes to take its full effect
2. an injectable anesthetic that requires less time to take effect and may provide a slightly longer period of anesthesia

In addition to anesthesia, acetaminophen is sometimes given. This helps reduce discomfort during the procedure and for several hours afterward. Giving a pacifier dipped in sugar water and swaddling a baby also can help reduce stress and discomfort.

Caring for a Circumcised Penis

Following circumcision, it is important to keep the area as clean as possible. Gently clean with warm water — do not use diaper wipes. Soapy water can be used if needed.

If there is a dressing on the incision, apply a new one (with petroleum jelly) whenever you change a diaper for the first day or two. Even after the dressing is no longer needed, put a dab of petroleum jelly on the penis or on the front of the diaper for 3 to 5 days. This can help avoid discomfort from rubbing and sticking to the diaper.

It usually takes between 7 to 10 days for a penis to heal. Initially the tip may appear slightly swollen and red and you may notice a small amount of blood on the diaper. You also may notice a slight yellow discharge or crust after a couple of days. This is part of the normal healing process.

If you notice any of the following problems, call your doctor right away:

• persistent bleeding or blood on the diaper (more than quarter-sized)
• increasing redness
• fever
• other signs of infection, such as worsening swelling or discharge, or the presence of pus-filled blisters
• not urinating normally within 12 hours after the circumcision

However, with quick intervention, almost all circumcision-related problems are easily treated.

Caring for an Uncircumcised Penis

As with a penis that’s circumcised, an uncircumcised one should be kept clean. Also, no cotton swabs, astringent or any special bath products are needed — just warm water every time you bathe your baby will suffice.

Initially, do not pull back the foreskin to clean beneath it. Over time, the foreskin will retract on its own so that it can be pulled away easily from the glans toward the abdomen. This happens at different times for different boys, but most can retract the foreskin by the time they reach puberty.

As your son grows up, teach him to wash beneath the foreskin by gently pulling it back from the glans, rinsing the glans and the inside of the foreskin with warm water, then pulling the foreskin back over the head of the penis.

The Circumcision Decision

After reviewing multiple studies on circumcision, the AAP reports that “the health benefits of newborn male circumcision outweigh the risks.” But at the current time, the scientific evidence is not strong enough for the AAP to recommend routine circumcision of all newborn boys. Instead, the AAP advises parents to learn the facts about circumcision and weigh the pros and cons.

In addition to considering the medical factors, religious and cultural beliefs might play a role. If these are important to you, they deserve to be seriously considered.

Talk to your doctor to help you make the choice that’s right for your son.

An orofacial (or-oh-FAY-shul) cleft is when a baby is born with an opening in the lip and/or roof of the mouth (palate). Cleft lip and cleft palate happen in about 1 or 2 of every 1,000 babies born in the United States each year, making it one of the most common birth defects.

Both cleft lip and cleft palate are treatable. Most kids can have surgery to repair them within the first year or two of life.

How a Cleft Lip or Palate Forms

During the first 6 to 10 weeks of pregnancy, the bones and tissues of a baby’s upper jaw, nose, and mouth normally come together (fuse) to form the roof of the mouth and the upper lip. A cleft happens when parts of the lip and mouth do not completely fuse together.

A cleft lip may just look like a small opening on the edge of the lip, or it could extend into the nose. It may also extend into the gums. A cleft palate can vary in size. It could affect just the soft palate, which is near the back of the throat, or it also could make a hole in the hard palate toward the front of the mouth.

A cleft can be on one side of the mouth (unilateral clefting) or on both sides of the mouth (bilateral clefting).

Most clefts fit into one of three categories:

1. cleft lip by itself — most common in boys
2. cleft palate by itself — most common in girls
3. cleft lip and cleft palate together — more common in boys

Usually, cleft lip is found when a baby is born, although some are seen on a prenatal ultrasound. A cleft palate is more difficult to see until the inside of a child’s mouth is examined carefully after birth.

Causes

Doctors don’t always know why a baby develops cleft lip or cleft palate, but many clefts are thought to be a combination of genetic (inherited) and environmental factors (like certain medications or vitamin deficiencies). Both mothers and fathers can pass on a gene or genes that cause cleft palate or cleft lip. Clefts happen more often in children of Asian, Latino, or Native American descent.

Taking certain medicines (such as some anti-seizure medications) during pregnancy can increase a woman’s chances of having a baby with a cleft lip or palate. Similarly, moms who don’t get the right amount of prenatal nutrients (for example, not enough folic acid) may increase their baby’s risk of having a cleft. A mother’s exposure to certain chemicals also may cause a cleft.

Women who smoke cigarettes, use drugs, or drink alcohol during pregnancy also increase their baby’s risk for birth defects. Research has shown that moms who binge drink (drinking four or more drinks in a short period of time) during the first weeks of pregnancy have a higher risk of having a baby with a facial birth defect like a cleft lip or cleft palate.

Related Health Problems

As you might imagine, cleft lip and cleft palate can affect many actions of the mouth and face. Children born with cleft lip or cleft palate might have issues related to their feeding, hearing, teeth, and speech.

Feeding Problems

Babies with just a cleft lip don’t usually have feeding problems. But when the palate is involved, feeding can be a bigger challenge.

Normally, the palate prevents food and liquids from entering the nose. A cleft palate causes babies to swallow a lot of air and regurgitate food into the nose. It also makes it harder for babies to latch on and suck during breastfeeding or bottle feeding. As a result, a baby with a cleft palate may need a special nipple and bottle to receive pumped breast milk or formula. Breastfeeding moms might want to talk with a lactation consultant, who can offer more guidance and suggestions.

Babies with feeding issues should be seen regularly by a doctor to make sure that they’re gaining weight well.

Middle Ear Fluid Buildup and Hearing Loss

Many children with cleft palate are at risk for fluid buildup in the middle ear. This fluid can’t pass through the Eustachian (yoo-STAY-shun) tube as it should, which can lead to ear infections and even hearing loss. So kids with cleft palate usually need ear tubes placed in their eardrums to help drain the fluid and improve hearing.

Kids with cleft palate should have their ears and hearing checked once or twice a year, or more if they are having hearing problems.

Dental Problems

Children with a cleft lip and palate often have dental problems. These can include small teeth, missing teeth, extra teeth (called supernumerary), or teeth that are out of position. They may have a defect in the gums or alveolar ridge (the bone that supports the teeth). Ridge defects can displace, tip, or rotate permanent teeth or prevent permanent teeth from coming in properly.

Regular visits with a pediatric dentist who specializes in cleft lip and palate are important. The dentist will check a child’s mouth growth and development, identify any problems, and make treatments when needed.

Speech Problems

Kids with cleft lip have fewer speech problems than those with cleft palate. About 1 in 5 kids with cleft palate have speech problems after surgical repair. Most often, this means that a child’s voice is hypernasal (sounding like the child is talking through the nose). This happens because the palate doesn’t move well enough to prevent air from leaking out of the nose.

Children with clefts also can have other types of speech problems that aren’t to the cleft; for example, age-related errors such as saying “wed” instead of “red.” Sometimes, the dental problems associated with the cleft will distort some sounds, particularly “s,” “sh,” “ch,” and “j.”

A speech-language pathologist can check a child’s speech and language skills and recommend treatment if needed.

Treatment Team

If your child has a cleft lip and/or palate, your pediatrician will talk to you about a cleft lip and palate treatment team. This team of health care professionals will work together to meet your family’s needs and, ultimately, help your child transition to adult care.

Besides the pediatrician, your child’s treatment team may include:

• plastic surgeon
• ear, nose, and throat physician (otolaryngologist)
• oral surgeon
• orthodontist
• dentist
• speech-language pathologist
• audiologist
• nurse
• social worker
• psychologist or therapist
• geneticist
• team coordinator

Your child might visit this care team a few times a year, depending on his or her needs. Who is seen during a visit depends on the care team’s structure and your child’s needs. The team coordinator will help organize the visits, and the team should communicate with your doctor about the treatment plan.

Surgical Treatment

A cleft lip is usually surgically repaired in the hospital using general anesthesia when a child is 3 to 6 months old. If the cleft lip is wide, special procedures like lip adhesion or a molding plate device might help bring the parts of the lip closer together before the lip is fully repaired. Cleft lip repair usually leaves a small scar on the lip under the nose.

At 9-12 months of age, a cleft palate usually can be repaired. Plastic surgeons connect the muscles of the soft palate and rearrange the tissues to close the cleft. This surgery requires general anesthesia and a short hospital stay for recovery.

The goal of surgery is to create a palate that works well for speech. Some kids, however, will continue to sound nasal after cleft palate repair, and some may develop a nasal voice later on.

More surgeries may be needed as children grow older and their facial structure changes — this can include surgeries like pharyngoplasty, which helps improve speech, or alveolar bone grafts, which help provide stability for permanent teeth. A bone graft closes gaps in the bone or gums near the front teeth and is usually done when kids are between 6 and 10 years old.

As children become teens, they will likely want to (and should) be more involved in their care. They may want to have their scars made less noticeable, improve the appearance of their nose and upper lip, or improve their bite with orthognathic surgery. These operations may improve speech and breathing, overbites/underbites, and appearance.

Dental and Orthodontic Treatment

Maintaining healthy teeth and preventing cavities is very important for kids with cleft lip and palate, who can have more dental problems than other kids. They should see a dentist regularly and brush and floss every day.

Kids with cleft lip and palate may begin orthodontic treatment as early as 6 years of age. It may start with palatal expansion, a process that makes the width of the palate normal. Later, it may involve braces to position the teeth. Your orthodontist will discuss these issues with you.

Some kids with a cleft might be missing a permanent tooth, which can be replaced with a removable appliance or, in early adulthood, a dental implant.

Speech Therapy

Some kids will need speech therapy after a repair is done. The speech-language pathologist will closely monitor your child’s progress and talk with you about whether therapy is needed.

Dealing With Emotional and Social Issues

It can be hard when kids miss school for frequent doctor’s appointments, or when speech problems prevent them from communicating well with their peers. In spite of these and other social, psychological, and educational challenges, kids with clefts just want to be treated like everyone else.

Children may face teasing and bullying because of how a cleft lip and palate look. If your child is teased, talk about it and be a patient listener. Try to give your child tools to confront teasers. Find out what your child would like to say to them and practice it together.

Some kids struggle growing up with a cleft lip or cleft palate and might need help handling certain situations. The psychologists and social workers on the treatment team can help guide you through these difficult times, so turn to them if your child needs added support. The good news is that most kids with cleft lip or cleft palate grow up to be healthy, happy adults.

As your child nears the teen years, remember that your interactions may change. You could be his or her greatest confidante, or your child may not share his or her worries with you. Either way, stay open to communication and support your child with these tips:

• Encourage your child to be confident and not allow the cleft to define who he or she is.
• Make your home a warm, supportive, and accepting place where individual worth and accomplishments are celebrated.
• Encourage your child’s friendships and relationships. Make friends with people who are different from you and lead by example.
• As for all kids, being involved in sports, music, and other activities will go a long way toward helping kids with clefts realize their self-worth.
• Give your child the freedom to make decisions and take appropriate risks. Having chances to make decisions early on — like picking out which clothes to wear or foods to eat — gives kids the confidence and skills to make bigger decisions later. It will help them become more independent.
• If your child — especially a young child — wants to talk to the class about cleft lip and palate, set up something with the teacher. Consider asking someone from the treatment team to attend. But remember that your child may need an extra boost of confidence to get up in front of the class, so give lots of encouragement.

Sometimes called a “bionic ear,” the cochlear implant offers the hope of gaining or restoring the ability to sense sound for some people with significant hearing loss.

What Is a Cochlear Implant?

A cochlear implant is a surgically implanted device that helps overcome problems in the cochlea (KO-klee-uh). The cochlea are snail-shaped, curled tubes near nerves in the ears. They transform sound vibrations reaching the ear into signals that can be sent to the auditory nerve (or hearing nerve). The auditory nerve then sends these signals to the brain, where they’re translated into recognizable sounds.

If important parts of the cochlea aren’t working as they should and the auditory nerve isn’t stimulated, there’s no way for the sounds to get to the brain. As a result, hearing doesn’t happen. This is called sensorineural hearing loss.

By completely bypassing the damaged part of the cochlea, the cochlear implant uses its own electrical signals to stimulate the auditory nerve, allowing the person to hear.

About Normal Hearing

The ear is made up of three parts, and in normal hearing, sound passes through all three on the way to the brain:

1. The outer ear: This is the outer, visible part of the ear and the ear canal. When a person hears a sound, the outer ear captures the sound vibration and sends it through the ear canal to the middle ear.
2. The middle ear: This consists of the eardrum and three tiny bones (the malleus, incus, and stapes). The sound vibration from the outer ear causes motion in these bones.
3. The inner ear: This is where the cochlea are. The motion of the bones in the middle ear makes the fluid in the cochlea move, which stimulates the hair cells (the thousands of tiny hearing receptors inside the cochlea). The hair cells bend back and forth and send chemical signals to the auditory nerve, which carries these signals to the brain, where they’re interpreted.

Hair cells can be damaged or destroyed through aging, heredity, disease, infection, or repeated or severe exposure to loud noise. If the hair cells don’t work, the auditory nerve can’t be stimulated and can’t send information to the brain. So, the person won’t be able to hear.

Hearing loss can be mild, moderate, or severe, depending on the number of hair cells that are defective, damaged, or destroyed. People with mild or moderate hearing loss may find that hearing aids help (hearing aids make sounds louder). Those with profound or severe hearing loss might even have trouble understanding loud sounds. A hearing aid won’t help in these cases, so a doctor might recommend a cochlear implant.

What a Cochlear Implant Does

The cochlear implant artificially stimulates the inner ear area with electrical signals, which sends those signals to the auditory nerve, letting a person hear.

Although sound quality from a cochlear implant is different from that in normal hearing, the cochlear implant lets someone sense sound that he or she couldn’t hear otherwise. And regular improvements to the way the implants work are helping to make the sound even more natural. Most infants, even if they never heard before, will be able to make sense of these sounds and develop speech and language.

A cochlear implant consists of an implant package, which is secured inside the skull, and a sound and speech processor, which is worn externally (outside the body). Several components of the cochlear implant work together to receive sound, transfer it to the auditory nerve, and send it to the brain.

The cochlear implant package is made up of:

• a receiver-stimulator that contains all of the electronic circuits that control the flow of electrical pulses into the ear
• an antenna that receives the signals from the external sound and speech processor
• a magnet that holds the external sound and speech processor in place
• one wire containing electrodes that are inserted into the cochlea (the number of electrodes can vary depending on the cochlear implant model type used). The electrodes act much like normal functioning hair cells and provide electrical charges to stimulate the auditory nerve.

The sound and speech processor is a minicomputer that processes sound into digital information, and then sends that information to the implant package in the form of electrical signals. This is worn externally and looks a lot like a normal hearing aid. Depending on the type of sound and speech processor used, it can either be worn as a headset behind the ear or in a belt, harness, or pocket.

The sound and speech processor is made up of:

• a sound and speech processor (which can either be a body-level model that can be clipped onto clothing like a portable radio, or an ear-level model that’s hooked over the ear)
• a microphone
• a transmitter that sends the signals to the cochlear implant package. The transmitter also includes a magnet.

For the cochlear implant to work, the implant package and the sound and speech processor must be aligned — that’s what the magnets are for. By lining up the magnets, both the implant package and sound and speech processor are secured and work together. If they aren’t completely aligned, the device doesn’t work and the person can’t hear.

How a Cochlear Implant Works

Knowing how a cochlear implant works may help kids better understand their new bionic ear and the cool technology behind it that allows them to hear better.

Here’s how the implant works:

• The microphone picks up sound.
• Sound is sent to the sound and speech processor.
• The processor analyzes the sound and converts it into an electrical signal. (The signal contains information that determines how much electrical current will be sent to the electrodes.)
• The transmitter sends the signal to the implant package, where it’s decoded.
• The implant package determines how much electric current should pass to the electrodes and sends the signal. The amount of electric current determines loudness, and the position of the electrodes determines the sound’s pitch.
• The nerve endings in the cochlea are stimulated and the message is sent to the brain along the auditory nerve.
• The brain interprets the sound and the person hears.

Cochlear Implant Surgery

Surgery for a cochlear implant takes 2–4 hours and uses general anesthesia (which keeps a patient completely unconscious). The surgeon will place and secure the implant package under the skin and inside the skull, then thread the wires containing the electrodes into the spirals of the cochlea.

To secure the implant, the surgeon first drills a 3- to 4-millimeter bed in the temporal bone (the skull bone that contains part of the ear canal, the middle ear, and the inner ear). Then, the surgeon opens up the bone behind the ear to allow access to the middle ear. A small hole is drilled in the cochlea and the wires containing the electrodes are inserted. The implant package is then secured and the incision is closed with stitches.

After cochlear implant surgery, a child:

• will probably be able to go home the next day
• will have to wear a dressing over the implant area for 24 hours
• might be off-balance or dizzy for a few days
• may have mild to moderate pain (the doctor may recommend giving pain medicines)
• won’t have to have the stitches removed (they’re absorbable and dissolve on their own)
• can lie on the side of the cochlear implant in a few days

About 2 to 4 weeks after surgery, the sound and speech processor is matched with the implant package and is programmed and fine-tuned to meet the child’s individual hearing needs.

Nowadays, children who are born deaf or with a profound hearing loss in both ears can even receive two cochlear implants, one for each ear, at the same time. This is a great advance as it requires only one surgery.

Learning to Use a Cochlear Implant

Because the hair cell damage, electrical signal patterns, and sensitivity of the auditory nerve are different for each person, a specialist must fine-tune the sound and speech processor for every patient.

By measuring the lowest and highest current for each electrode, the clinician finds the softest and loudest sounds that will be heard (each electrode produces a different sound with different pitch). The sound and speech processor matches sounds on different electrodes with different volumes and attempts to create an accurate version of the original sound. However, because a limited number of electrodes are taking over the function of the thousands of hair cells in a normal ear, sounds won’t be totally “natural.” However, infants who never heard before will be able to make great sense of these sounds and will quickly learn language.

After the first few programming sessions, the user begins to pick up sounds with the implant, but giving the implant full power is a gradual process that takes several months. In children who are born deaf, the stimulation from the implant will allow them to develop the brain pathways necessary to hear sounds and develop speech and language. This is an extended process with programming and intensive therapy that often lasts for several years.

During the programming process, the user attends speech and language therapy sessions to help identify and interpret the new sounds he or she is hearing. An important part of the therapy is parent education and training.

Therapy will help a child develop and understand spoken language through detecting, imitating, and associating meanings of sounds. These sessions last at least a year, along with parent education and training programs. In many cases, therapy has helped kids with cochlear implants develop speech and language on par with their peers.

Some families choose to have implants in both ears. This can help with speech detection when there is background noise.

Can an Implant Restore Hearing for Everyone?

Cochlear implants are very successful for some people, but not everyone is a candidate to receive one. Children 12 months of age or older with profound hearing loss in both ears are usually excellent candidates, but not every child is eligible.

Common reasons that a child might not be eligible for a cochlear implant include:

• the child’s hearing is “too good” (meaning the child can hear some sound and speech with hearing aids)
• the hearing loss isn’t due to a problem with the cochlea
• the child has had profound deafness for a long time
• the auditory nerve itself is damaged or absent

Each potential candidate must be evaluated by a cochlear implant team to see whether a cochlear implant is the best option.

Benefits of an implant can vary. The rehabilitation period can be long, and many factors (such as the condition of the auditory nerve or the presence of scar tissue in the cochlea) can affect the success of the implant.

The doctor or surgeon will help parents understand what an implant can reasonably achieve for their child.

Enlarged Adenoids

Adenoids are a patch of tissue that sits at the very back of the nasal passage. Like tonsils, adenoids help keep the body healthy by trapping harmful bacteria and viruses that you breathe in or swallow. Although you can see the tonsils at the back of the throat, adenoids aren’t directly visible.

Adenoids do important work as infection fighters for babies and young children. But they become less important once a child gets older and the body develops other ways to fight germs. In kids, adenoids usually begin to shrink after about 5 years of age and often practically disappear by the teen years.

Because adenoids trap germs that enter the body, adenoid tissue sometimes temporarily swells (becomes enlarged) as it tries to fight off an infection. The swelling sometimes gets better, but sometimes adenoids can get infected. If the adenoids get infected a lot, a doctor might recommend they be removed. Often, tonsils and adenoids are surgically removed at the same time.

Symptoms of Enlarged Adenoids

These symptoms are often associated with enlarged adenoids:

• difficulty breathing through the nose
• breathing through the mouth
• talking as if the nostrils are pinched
• noisy breathing
• snoring
• stopped breathing for a few seconds during sleep (obstructive sleep apnea)
• frequent “sinus” symptoms
• ongoing middle ear infections or middle ear fluid in a school-aged child

If enlarged adenoids are suspected, the doctor may ask about and then check your child’s ears, nose, and throat, and feel the neck along the jaw. To get a really close look, the doctor might order X-rays or look into the nasal passage with a tiny telescope. For a suspected infection, the doctor may prescribe different types of medicine like pills or liquids. Nasal steroids (a liquid that is sprayed into the nose) might also be prescribed to help reduce swelling in the adenoids.

When Is Surgery Necessary?

If enlarged or infected adenoids keep bothering your child and are not controlled by medication, the doctor may recommend surgically removing them with an adenoidectomy. This may be recommended if your child has one or more of the following:

• difficulty breathing
• obstructive sleep apnea
• repeated infections
• frequent sinus infections
• ear infections, middle ear fluid, and hearing loss requiring a second or third set of ear tubes

Having your child’s adenoids removed is especially important if repeated infections lead to sinus and ear infections. Badly swollen adenoids can interfere with the ability of the middle ear space to stay ventilated. This can sometimes lead to infections or middle ear fluid causing a temporary hearing loss. So kids whose infected adenoids cause frequent earaches and fluid buildup might also need an adenoidectomy at the time of their ear tube surgery.

And although adenoids can be taken out without the tonsils, if your child is having tonsil problems, they may be removed at the same time. A tonsillectomy with an adenoidectomy is a common pediatric operation.

What Happens During Surgery

Surgery, no matter how common or simple the procedure, can be frightening for both kids and parents. You can help prepare your child for surgery by talking about what to expect. During the adenoidectomy:

• Your child will receive general anesthesia. This means the surgery will be performed in an operating room so that an anesthesiologist can monitor your child.
• Your child will be asleep for about 20 minutes.
• The surgeon can get to the tonsils and/or the adenoids through your child’s open mouth — there’s no need to cut through skin.
• The surgeon removes the adenoids and then controls any bleeding.

Your child will wake up in the recovery area. In most cases, a child can go home the same day as the procedure. Some children may need to stay overnight for observation.

The typical recovery after an adenoidectomy often involves several days of moderate pain and discomfort, which may include sore throat, runny nose, and bad breath.

In less than a week after surgery, everything should return to normal and the problems caused by the adenoids should be gone. There are no stitches to worry about, and the adenoid area will heal naturally.

At one time or another, many adults have had heartburn (an uncomfortable feeling in the chest) after eating a big meal or spicy foods.

When these symptoms happen often or aren’t tied to certain ingredients, they might be due to gastroesophageal reflux (GER), also called reflux.

But GER isn’t just a problem for adults — kids can have it, too, even babies. In infants, it can cause vomiting and fussiness after feeding. And in older kids and teens, GER can lead to heartburn, and stomach and chest discomfort.

Most kids outgrow GER over time but some will need medical treatment. Reflux that causes problems like poor growth, vomiting, or damage to the esophagus is called GERD (gastroesophageal reflux disease). GERD is more serious than GER and is usually treated with medicine.

About GER

The burping, heartburn, and spitting up associated with GER are the result of acidic stomach contents moving backward into the esophagus. This can happen because the muscle that connects the esophagus to the stomach (the esophageal sphincter) relaxes at the wrong time or doesn’t properly close.

Many people have reflux regularly and it’s not usually a cause for concern. But with GER, reflux happens more often and causes noticeable discomfort. After nearly all meals, GER causes heartburn (also known as acid indigestion), which feels like a burning sensation in the chest, neck, and throat.

In babies with GER, breast milk or formula regularly refluxes into the esophagus, and sometimes out of the mouth. Sometimes babies regurgitate forcefully or have “wet burps.” Most babies outgrow GER between the time they are 1 or 2 years old.

But in some cases, GER symptoms last. Kids with developmental or neurological conditions, such as cerebral palsy, are more at risk for GER and can have more severe, lasting symptoms.

Symptoms of GER

Heartburn is the most common symptom of GER in kids and teens. It can last up to 2 hours and tends to be worse after meals. In babies and young children, GER can lead to problems during and after feeding, including:

• frequent regurgitation or vomiting, especially after meals
• choking or wheezing (if the contents of the reflux get into the windpipe and lungs)
• wet burps or wet hiccups
• spitting up that continues beyond a child’s first birthday (when it stops for most babies)
• irritability or inconsolable crying after eating
• refusing to eat or eating only small amounts
• failure to gain weight

Some of these symptoms may become worse if a baby lies down or is placed in a car seat after a meal.

Complications of GER

Some children develop complications from GER. The constant reflux of stomach acid can lead to:

• breathing problems (if the stomach contents enter the trachea, lungs, or nose)
• redness and irritation in the esophagus, a condition called esophagitis
• bleeding in the esophagus
• scar tissue in the esophagus, which can make swallowing difficult

Because these complications can make eating painful, GER can interfere with proper nutrition. So if your child isn’t gaining weight as expected or is losing weight, it’s important to talk with your doctor.

Diagnosing GER

In older kids, doctors usually diagnose reflux by doing a physical exam and hearing about the symptoms. Try to keep track of the foods that seem to bring on symptoms in your child — this information can help the doctor determine what’s causing the problem.

In younger children and babies, doctors might run these tests to diagnose GER or rule out other problems:

• Barium swallow. This is a special X-ray that can show the refluxing of liquid into the esophagus, any irritation in the esophagus, and abnormalities in the upper digestive tract. For the test, your child must swallow a small amount of a chalky liquid (barium). This liquid appears on the X-ray and shows the swallowing process.
• 24-hour impedance-probe study. This is considered the most accurate way to detect reflux and the number of reflux episodes. A thin, flexible tube is placed through the nose into the esophagus. The tip rests just above the esophageal sphincter to monitor the acid levels in the esophagus and to detect any reflux.
• Milk scans. This series of X-ray scans tracks a special liquid as a child swallows it. The scans can show whether the stomach is slow to empty liquids and whether the refluxed liquid is being inhaled into the lungs.
• Upper endoscopy. In this test, doctors directly look at the esophagus, stomach, and a portion of the small intestines using a tiny fiber-optic camera. During the procedure, doctors also may biopsy (take a small sample of) the lining of the esophagus to rule out other problems and see whether GER is causing other complications.

Treating GER

Treatment for GER depends on the type and severity of the symptoms.

In babies, doctors sometimes suggest thickening the formula or breast milk with up to 1 tablespoon of oat cereal to reduce reflux. Making sure the baby is in a vertical position (seated or held upright) during feedings can also help.

Older kids often get relief by avoiding foods and drinks that seem to trigger GER symptoms, including:

• citrus fruits
• chocolate
• food and drinks with caffeine
• fatty and fried foods
• garlic and onions
• spicy foods
• tomato-based foods and sauces
• peppermint

Doctors may recommend raising the head of a child’s bed 6 to 8 inches to minimize reflux that happens at night. They also may try to address other conditions that can contribute to GER symptoms, including obesity and certain medicines — and in teens, smoking and alcohol use.

If these measures don’t help relieve the symptoms, the doctor may also prescribe medicine, such as H2 blockers, which can help block the production of stomach acid, or proton pump inhibitors, which reduce the amount of acid the stomach produces.

Medications called prokinetics are sometimes used to reduce the number of reflux episodes by helping the lower esophageal sphincter muscle work better and the stomach empty faster.

In rare cases, when medical treatment alone doesn’t help and a child is failing to grow or develops other complications, a surgical procedure called fundoplication might be an option. This involves creating a valve at the top of the stomach by wrapping a portion of the stomach around the esophagus.

When to Call the Doctor

If your child has GER symptoms, talk with your doctor. With proper diagnosis and treatment, kids can get relief and avoid longer-term health problems.

Many people are surprised to learn that hernias are fairly common in kids. Babies (especially preemies) can even be born with them.

Hernias in kids can be treated (hernia repair is the one of the most common surgeries performed on children), but it’s important to recognize their symptoms so that you can get your child the appropriate medical care.

About Hernias

When part of an organ or tissue in the body (such as a loop of intestine) pushes through an opening or weak spot in a muscle wall, it can protrude into a space where it does not belong. This protrusion is a hernia, which may look like a bulge or lump.

Some babies are born with various small openings inside the body that will close at some point. Nearby tissues can squeeze into such openings and become hernias. Unlike hernias seen in adults, these areas are not always considered a weakness in the muscle wall, but a normal area that has not yet closed.

Sometimes tissues can squeeze through muscle wall openings that are only meant for arteries or other tissues. In other cases, strains or injuries create a weak spot in the muscle wall, and part of a nearby organ can be pushed into the weak spot so that it bulges and becomes a hernia.

Types of Hernias

There are different types of hernias, and each requires different levels of medical care.

In many infant and childhood hernias, the herniated tissues may protrude only during moments of physical pressure or strain. A prominent bulge might only be noticeable when a child is crying, coughing, or straining, and it may seem to retract or go away at other times. Hernias in this state are called reducible and are not immediately harmful.

Sometimes tissue can become trapped in an opening or pouch and do not retract. These are incarcerated hernias, and are a serious problem requiring immediate medical attention. For example, a loop of intestine that is caught and squeezed in the groin area may block the passage of food though the digestive tract.

Symptoms of an incarcerated hernia can include pain, vomiting, and irritability. If you touch the bulge it has created, it may feel hard.

A doctor can usually free the trapped tissues by gently squeezing the lump and trying to force it back into the body opening. Because incarcerated hernias can be painful, the doctor usually provides pain medication during this procedure. Surgery is usually required within a few days to prevent development of another incarcerated hernia.

The most serious type of hernia is a strangulated hernia, in which the normal blood supply is cut off from the trapped tissue. Without that blood supply, the strangulated tissue cannot get oxygen and will die. Surgery is required immediately to dislodge the tissue so that oxygen can get to it again.

The two most common hernias in kids are inguinal hernias in the groin area and umbilical hernias in the belly-button area.

Inguinal Hernias

In infants, an inguinal hernia is most often caused by a protrusion of a loop or portion of intestine or a fold of membrane from the abdomen — or in girls, from an ovary or fallopian tube — through an opening into the groin (the area where the abdomen meets the top of the thigh). The opening is caused by the presence of a fold of the peritoneal membrane, which produces a sac. Within this sac, the loop of bowel can protrude.

The hernia is apparent as a bulge in the groin area, especially when the child cries, coughs, or stands.

Sometimes, in boys, the inguinal hernia extends beyond the groin into the scrotum (the sac that holds the testicles). In girls, it can extend to one of the outer labia (the larger lips of tissue around the vaginal opening). In these cases, an enlargement or swelling can be seen that extends from the groin into the scrotum or labium.

More common on the right side, inguinal hernias occur far more often in boys than girls and are most common in preemies, baby boys with undescended testicles, and kids with cystic fibrosis. Kids with a family history of hernias are also at risk.

Other conditions that may look like inguinal hernias, but are not:

• A communicating hydrocele is similar to a hernia, except that fluid causes the bulge rather than protruding tissue. Depending on its location, the hydrocele may be left to disappear in a year or two or it may be treated with surgery. In infants, the hydrocele may not require surgery, as many go away by the second birthday. Some can change size depending on how much fluid goes in and out, and some may appear bluish because the membrane that causes the hydrocele is blue.
• Occasionally, a retractile testicle (a testicle that retracts from the scrotum from time to time) causes a bulge in the groin area. It may not need treatment but should be evaluated by a pediatric specialist.
• A femoral hernia is rare in kids and can be confused with an inguinal hernia. It consists of tissues that have pushed in alongside an artery into the top of the thigh. It appears as a bulge at the top of the thigh, just below the groin.

Umbilical Hernias

Some babies are born with a weakness or opening in the abdominal muscles around the belly button (under the skin) through which some abdominal membrane or small intestine protrudes.

The soft bulge this creates is an umbilical hernia. It is most obvious when the baby cries, coughs, or strains. Umbilical hernias are more common in females, those of African heritage, and low birth weight babies. These hernias range in size from less than ½ inch (2 centimeters) to more than 2 inches (6 centimeters).

In most instances an umbilical hernia causes no discomfort. Usually, a doctor can easily push it back in. An infant’s umbilical hernia (unlike an adult’s) rarely obstructs or strangulates. In fact, most umbilical hernias, even the larger ones, tend to close up on their own by age 2. That’s why the doctor usually advises waiting and watching this kind of hernia in an infant rather than operating.

Surgery is necessary only if the hernia is very large; grows in size after age 1 or 2; fails to heal by age 4 or 5; or the child develops symptoms of obstruction or strangulation, like swelling, bulging, vomiting, fever, and pain. If such symptoms develop, call the doctor immediately.

Signs and Symptoms

If you think that your child may have a hernia, call your doctor immediately. And ask yourself:

• Is the bulge present when your child is straining, crying, coughing, or standing, but absent when your child is sleeping or resting? This could indicate a reducible hernia.
• Is the bulge present all the time, but with no other symptoms? This could be a hydrocele or something else.
• Has the groin area suddenly begun to swell? Do you notice any discoloration of the bulging area or a “swollen” abdomen? Is your child irritable, complaining of pain, constipated, or vomiting? These are signs of an incarcerated hernia, which calls for immediate attention. See a doctor immediately or take your child to the emergency department.
• Is the area swollen, red, inflamed, and extremely painful? Has your child developed a fever? These might be symptoms of a strangulated hernia. Call your doctor and then go directly to the hospital emergency department.

Treatment

Once an inguinal hernia is diagnosed, surgery will be done to prevent it from becoming incarcerated. During surgery, the herniated tissue is put back into its proper space, and the opening or weakness that permitted it to form is closed or repaired.

Surgery to correct inguinal hernias is performed on kids of all ages, sometimes even on premature babies.

Inguinal hernia surgery in kids is usually performed on an outpatient basis with no overnight stay in the hospital, but some kids, particularly young infants, may be kept in the hospital overnight for observation.

The period of recuperation for kids is fairly short. Most can resume normal activities about 7 days after surgery, with the doctor’s approval. Until that time, kids should avoid strenuous activity such as bicycle riding and tree climbing. Of course, if you notice any signs of problems after the surgery, such as bleeding, swelling, or fever, call your doctor.

About Intussusception

Intussusception (in-tuh-suh-SEP-shun) is the most common abdominal emergency affecting children under 2 years old. It happens when one portion of the bowel slides into the next, much like the pieces of a telescope.

When this “telescoping” happens, the flow of fluids and food through the bowel can become blocked, the intestine can swell and bleed, and the blood supply to the affected part of the intestine can get cut off. Eventually, this can cause part of the bowel to die.

Intussusception happens in 1 to 4 out of every 1,000 infants and is most common in babies 5 to 9 months old, though older children also can have it. Boys get intussusception more often than girls.

Signs and Symptoms

Babies and children with intussusception have intense abdominal pain, which often begins suddenly and causes the child to draw the knees up toward the chest. The pain often makes the child cry very loudly. As it eases, the child may stop crying for a while and may seem to feel better. The pain usually comes and goes like this, but can become very strong when it returns.

Symptoms also can include:

• abdominal swelling
• vomiting
• vomiting up bile, a bitter-tasting yellowish-green fluid
• passing stools (poop) mixed with blood and mucus, known as currant jelly stool
• grunting due to pain

As the illness continues, the child may gradually become weaker. He or she may develop a fever and appear to go into shock, a life-threatening medical problem in which lack of blood flow to the body’s organs causes the heart to beat quickly and blood pressure to drop.

Some babies with intussusception may just appear drowsy without vomiting, have stool changes, or have abdominal swelling.

Causes

Most of the time, doctors don’t know what causes intussusception. In some cases, it might follow a recent attack of gastroenteritis (or “stomach flu”). Bacterial or viral gastrointestinal infections may cause swelling of the infection-fighting lymph tissue that lines the intestine, which may result in one part of the intestine being pulled into the other.

In kids younger than 3 months of age or older than 5, intussusception is more likely to be caused by an underlying condition like enlarged lymph nodes, a tumor, or a blood vessel abnormality in the intestines.

Diagnosis and Treatment

Doctors usually check for intussusception if a child is having repeat episodes of pain, drawing up the legs, vomiting, feeling drowsy, or passing stools with blood and mucous.

During the visit, the doctor will ask about the child’s overall health, family health, any medications the child is taking, and any allergies the child may have. Next, the doctor will examine the child, paying special attention to the abdomen, which may be swollen or tender to the touch. Sometimes the doctor can feel the part of the intestine that’s involved.

If the doctor suspects intussusception, the child may be sent to an emergency room (ER). Usually, doctors there will ask a pediatric surgeon to see the child right away. The ER doctor might order an abdominal ultrasound or X-ray, which can sometimes show a blockage in the intestines. If the child looks very sick, suggesting damage to the intestine, the surgeon may take the child to the operating room right away to correct the bowel obstruction.

Two kinds of enemas (an air enema or a barium enema) often can diagnose and treat intussusception at the same time.

For an air enema, a small soft tube is placed in the rectum and air is passed through the tube. The air travels into the intestines and outlines the bowels on the X-rays. If intussusception is present it shows the doctors the telescoping piece in the intestine. At the same time, the pressure of the air unfolds the bowel that has been turned inside out and cures the blockage. Barium, a liquid mixture, is sometimes used in place of air to fix the blockage in the same way.

Both types of enema are very safe, and children usually do very well. However, it’s important to remember that the intussusception can return in 1 out of 10 cases. This usually happens within 72 hours following the procedure.

If the intestine is torn, an enema doesn’t work, or the child is too sick to try an enema, the child will need surgery. This is often the case in older children. Surgeons will try to fix the obstruction, but if too much damage has been done, that part of the bowel will be removed.

After treatment, the child will stay in the hospital and get intravenous (IV) feedings through a vein until he or she can eat and normal bowel function returns. Doctors will watch the child closely to make sure that the intussusception does not return. Some babies may also need antibiotics to prevent infection.

When to Call the Doctor

Intussusception is a medical emergency. If you’re worried that your child has some or all of the symptoms of intussusception, such as repeated crampy abdominal pain, vomiting, drowsiness, or passing of currant jelly stool, call your doctor or get emergency medical help immediately.

Most infants who are treated within the first 24 hours recover completely with no problems. But untreated intussusception can cause severe problems that get worse quickly. So it’s extremely important not to delay treatment — every second counts. Delayed treatment greatly increases the risk of irreversible tissue damage, tearing of the bowel, infection, and possibly death.

Why Surgery?

Many kids get middle ear infections (known as otitis media, or OM), usually when they’re between 6 months and 2 years old.

Some kids are particularly likely to get them because of environmental and lifestyle factors (like attendance at a group childcare, secondhand tobacco smoke exposure, and taking a bottle to bed).

Although these infections are fairly easy to treat, a child who has multiple ear infections that do not get better easily or has signs of hearing loss or speech delay may be a candidate for ear tube surgery.

During this surgery, small tubes are placed in the eardrums to ventilate the area behind the eardrum and keep the pressure equalized to atmospheric pressure in the middle ear.

About Otitis Media

The middle ear is an air-filled cavity located behind the eardrum. When sound enters the ear, it makes the eardrum vibrate, which in turn makes tiny bones in the middle ear vibrate. This transmits sound signals to the inner ear, where nerves relay the signals to the brain.

A small passage leading from the middle ear to the back of the nose — called the eustachian tube — equalizes the air pressure between the middle ear and the outside world. (When your ears pop while yawning or swallowing, the eustachian tubes are adjusting the air pressure in the middle ears.)

Infection

Bacteria or viruses can enter the middle ear through the eustachian tube and cause an infection — this often happens when a child has had a cold or other respiratory infection. When the middle ear becomes infected, it may fill with fluid or pus, particularly if the infection is caused by bacteria.

Pressure from this buildup pushes on the eardrum and causes pain, and because the eardrum cannot vibrate, the child may have a temporary decrease in hearing.

With treatment, a bacterial infection can be quickly cleared up. In most kids, the fluid will go away over time and normal hearing will return. Some research, though, suggests that long periods of hearing loss in young children can lead to delays in speech development and learning.

Symptoms and Diagnosis

Symptoms of otitis media include:

• pulling or rubbing the ears because of ear pain
• fever
• fussiness or irritability
• fluid leaking from the ear
• changes in appetite or sleeping patterns
• trouble hearing

Call your doctor if you think your child has an ear infection. He or she will perform a physical exam and look at your child’s eardrums. If a bacterial infection looks likely (often based on whether there is pus behind the eardrum), the doctor might decide to wait and see if the immune system will clear the infection without the use of antibiotics. If fever and pain last for more than 48 hours, then antibiotics may be prescribed. This is important to know since unnecessary use of antibiotics can lead to resistant bacteria.

In some cases, the doctor will insert a needle through the eardrum to remove a sample of the pus from the middle ear for a laboratory test. Called a tympanocentesis, this procedure can help the doctor decide which antibiotic to use.

Treatment

Although ear tube surgery is a fairly common procedure, surgery is not the first choice of treatment for otitis media. Antibiotics are often used to treat bacterial ear infections, but many ear infections are viral and cannot be treated with antibiotics. These infections need to get better on their own, and only time can help them heal.

But if your child has frequent ear infections that don’t clear up easily or a hearing loss or speech delay, the doctor may suggest surgery to drain fluid from the middle ear and insert a ventilation tube.

Because most kids have had infections in both ears, surgery is often done in both; this is called a bilateral myringotomy, or BMT. A tiny tube, called a pressure equalization (PE) or tympanostomy tube, is inserted into the eardrum to ventilate and equalize pressure in the middle ear. This will help to prevent future infections and the build-up of fluid, and will help normalize hearing.

The presence of the tiny hole in the eardrum from the tube doesn’t hurt hearing (in fact, kids with a speech or language delay from hearing loss often will have an improvement in their hearing). Depending on the type used, the tube remains in place for about 6 months to 18 months or longer.

Tympanostomy Tube Surgery

If your child is old enough to understand what surgery is, talk about what happens during ear tube surgery:

• Because your child will receive general anesthesia, the surgery will be done in a hospital so that an anesthesiologist can monitor your child. The procedure takes about 10 to 15 minutes.
• The surgeon will make a small hole in the eardrum and remove fluid from the middle ear using suction. Because the surgeon can reach the eardrum through the ear canal, there is no visible incision or stitches.
• The surgeon will finish by inserting a small metal or plastic tube into the hole in the eardrum.

Afterward, your child will wake up in the recovery area. In most cases, the total time spent in the hospital is a few hours. Very young children or those with significant medical problems may stay longer.

After Surgery

A tympanostomy tube helps prevent recurring ear infections by allowing air into the middle ear. Other substances, including water, may sometimes enter through the tube, but this is rarely a problem. Your surgeon might recommend earplugs for regular bathing or swimming.

In most cases, surgery to remove a tympanostomy tube isn’t necessary. The tube usually falls out on its own, pushed out as the eardrum heals. A tube generally stays in the ear anywhere from 6 months to 18 months, depending on the type of tube used.

If the tube remains in the eardrum beyond 2 to 3 years, however, it probably will be removed surgically to prevent a perforation in the eardrum or accumulation of debris around the tube.

While effective in reducing chronic ear infections, ear tubes are not always a permanent cure for otitis media. Up to 25% of kids who need ear tubes before the age of 2 may need them again.

Stem cells are cells in the body that have the potential to turn into anything, such as a skin cell, a liver cell, a brain cell, or a blood cell. Stem cells that turn into blood cells are called hematopoietic (heh-mat-uh-poy-EH-tik) stem cells. These cells are capable of developing into the three types of blood cells:

1. red blood cells that carry oxygen
2. white blood cells that fight infection
3. platelets that help blood to clot

Hematopoietic stem cells can be found in bone marrow (the spongy tissue inside bones), the bloodstream, and the umbilical cord blood of newborn babies.

A stem cell transplant (sometimes called a bone marrow transplant) can replenish a child’s supply of healthy hematopoietic stem cells after they have been depleted. It’s used to treat a wide range of diseases, including cancers like leukemia, lymphoma, neuroblastoma, Wilms tumor, and certain testicular or ovarian cancers; blood disorders; immune system diseases; and bone marrow syndromes.

Transplanted hematopoietic stem cells are put into the bloodstream through an intravenous (IV) line, much like a blood transfusion. Once in the body, they can produce healthy new blood and immune system cells.

Types of Transplants

The two main types of stem cell transplants are autologous (aw-TAHL-uh-gus) and allogeneic (al-uh-juh-NEE-ik). The type of transplant needed will depend on the child’s specific medical condition and the availability of a matching donor.

• Autologous hematopoietic stem cell transplant. With this type of transplant, patients act as their own donor. For instance, a child who is about to undergo cancer treatment will have his or her own stem cells removed (harvested) and frozen for later use. After the child receives chemotherapy and/or radiation, the stem cells are thawed and put back into the child’s body.

  This procedure may be done once or many times, depending on the need. Sometimes doctors will use extra-high doses of chemotherapy during treatment (to kill as many cancer cells as possible) if they know a patient will be getting a stem cell transplant soon after.

• Allogeneic hematopoietic stem cell transplant. With an allogeneic transplant, the stem cells come from a donor — often a sibling but sometimes another volunteer — whose cells are considered a “match” for the patient. The process of finding a match is called tissue typing (or HLA [human leukocyte antigen] typing). HLA is a protein on the surface of blood cells. Basically, the more “HLA markers” a child and the potential donor have in common, the greater the chance that the transplant will be successful.

  Unlike with an autologous transplant, there is a risk of a child’s body rejecting the donated cells. This means that the body’s own immune cells destroy the transplanted stem cells because they sense they are foreign. Sometimes, despite the donor being a good match, the transplant simply may not take. Other times, the donor cells can begin to make immune cells that attack the recipient’s body. This condition is called graft-versus-host disease, and can be quite serious. Fortunately, most cases are successfully treated with steroids and other medicines.

  Sometimes, an upside of graft-versus-host disease is that the newly transplanted cells recognize the body’s cancer cells as different or foreign, and actually work to fight them.

Transplantation

Stem cell transplantation is a very complex process that may span several months. A team of doctors is usually involved in determining if a child is a candidate and, if so, whether the transplant will be autologous or allogeneic.

For an allogeneic transplant, a compatible donor will be sought among family members or through a national registry of volunteers. Once a match is found, the donor’s stem cells will be harvested. Three different types of hematopoietic stem cells can be collected or harvested:

1. Peripheral blood stem cells are harvested from donated blood. The stem cells are separated and collected and the rest of the blood is returned to the donor.
2. Bone marrow stem cells are collected from the donor’s hip bone through a surgical procedure.
3. Cord blood stem cells are collected from the umbilical cord (the part of the placenta that delivers nutrients to a fetus) immediately after a baby is born and the umbilical cord is clamped and cut.

While all three types can replenish a patient’s blood and bone marrow cells, there are advantages and disadvantages to each. The doctor will suggest the best type of stem cell for your child’s illness.

The next step in the transplantation process is conditioning therapy, which kills unhealthy cells (like cancer cells) to make room for stem cells to grow and/or weakens the immune system so that there’s less chance of the body rejecting the new cells.

One type of conditioning therapy delivers high doses of chemotherapy and/or radiation to kill cells, destroy the bone marrow, and weaken the immune system. Most kids will get this type of therapy. Another type of conditioning therapy delivers lower doses of chemotherapy, radiation, or another treatment to weaken the immune system. The doctor will decide which type of conditioning therapy is best.

Soon after the conditioning phase, the transplant itself will be done through intravenous (IV) infusion, and healthy stem cells will be introduced to the child’s body. After the infusion, the child will be watched very closely to make sure the new stem cells are settling into the marrow and beginning to make new blood cells (called engrafting). Doctors will watch for any signs of rejection as well as graft-verses-host disease in kids with allogeneic transplants.

Engrafting takes an average of 2 weeks, but can be as quick as 1 week or as long as 6 weeks. Your child will receive medicines to promote engrafting and prevent rejection and graft-versus-host disease.

Recovery

Kids who receive stem cell transplants have a high risk of infection. During conditioning therapy and while the transplant is engrafting, their immune systems are weakened and unable to fight bacteria and other germs that enter the body. Children who receive an allogeneic transplant have an even greater risk of infection because they require medicines to further suppress their immune systems to reduce the chance of rejection.

Because of these risks, a child who’s had a stem cell transplant will not be released from the hospital until doctors are sure the transplant has successfully engrafted and the child is otherwise doing well.

Once released, a child needs very close monitoring and follow-up care. School and other public indoor areas may be off limits for 3 months to a year, and other places might be restricted as well. This is because for kids with a compromised immune system, even a simple infection like a common cold can be serious and even life-threatening if untreated.

Coping

The stress of having a child who is being treated for cancer or another serious condition can be overwhelming for a family. That stress can grow when treatment requires a long “isolation period,” as is necessary with a stem cell transplant.

To find out what support is available to you and your child, talk to your doctor, a hospital social worker, or child life specialist. Many resources are available that can help you get through this difficult time.

Many babies are born with an underdeveloped tear-duct system, a problem that can lead to tear-duct blockage, excess tearing, and infection.

Blocked tear ducts are common in infants; as many as one third may be born with this condition. Fortunately, more than 90% of all cases clear up by the time children are 1 year old with little or no treatment.

About Tear Ducts

Our eyes are continually exposed to dust, bacteria, viruses, and other things that could cause damage, and the eyelids and eyelashes play a key role in preventing that.

Besides being protective barriers, the lids and lashes also help the eyes stay moist. Without moisture, the corneas would dry out and could become cloudy or injured.

Working with the lids and lashes, the protective system of glands and ducts (called the lacrimal system) keeps eyes from drying out. Small glands at the edge of the eyelid produce an oily film that mixes with the liquid part of tears and keeps them from evaporating.

Lacrimal (or tear-producing) glands secrete the watery part of tears. These glands are located under the browbone behind the upper eyelid, at the edge of the eye socket, and in the lids.

Eyelids move tears across the eyes. Tears keep the eyes lubricated and clean and contain antibodies that protect against infection. They drain out of the eyes through two openings (puncta, or lacrimal ducts), one on each of the upper and lower lids.

From these puncta, tears enter small tubes called canaliculi or ducts, located at the inner corner of the eyelids, then pass into the lacrimal sac, which is next to the inner corner of the eyes (between the eyes and the nose).

From the lacrimal sacs, tears move down through the nasolacrimal duct and drain into the back of the nose. (That’s why you usually get a runny nose when you cry — your eyes are producing excess tears, and your nose can’t handle the additional flow.) When you blink, the motion forces the lacrimal sacs to compress, squeezing tears out of them, away from the eyes, and into the nasolacrimal duct.

The nasolacrimal duct and the lacrimal ducts are also known as tear ducts. It’s the nasolacrimal duct that’s usually involved in tear-duct blockage in babies.

Causes of Blocked Tear Ducts

Many babies are born without a fully developed nasolacrimal duct. This is called congenital nasolacrimal duct obstruction or dacryostenosis. Most commonly, an infant is born with a duct that is too narrow or has a web of tissue blocking the duct, so it doesn’t drain properly or becomes blocked easily. Most kids outgrow this by the first birthday.

Other causes of blockage, especially in older kids, are rare. Some kids have nasal polyps, which are cysts or growths of extra tissue in the nose at the end of the tear duct. A blockage also can be caused by a cyst or tumor in the nose, but again, this is very unusual in children.

Trauma to the eye area or an eye injury that lacerates (cuts through) the tear ducts also could block a duct, but reconstructive surgery right after the accident or injury may prevent this.

Signs of Blocked Tear Ducts

Babies with blocked tear ducts usually develop symptoms between birth and 12 weeks of age, although the problem might not be apparent until an eye becomes infected. The most common signs are excessive tearing, even when a baby is not crying (this is called epiphora). You also may notice pus in the corner of the eye, or that your child wakes up with a crust over the eyelid or in the eyelashes.

Babies with blocked tear ducts can develop an infection in the lacrimal sac called dacryocystitis. Signs include redness at the inner corner of the eye and a slight tenderness and swelling or bump at the side of the nose.

Some infants are born with a cyst in the lacrimal sac, causing a swollen blue bump called a dacryocystocele to appear next to the inside corner of the eye.

Although this condition should be watched closely by a doctor, it doesn’t always lead to infection and can be treated at home with firm massage and observation. If it becomes infected, topical (applied to the skin) antibiotics might be needed.

However, with some infections, a baby may need to be treated in a hospital with IV (intravenous, given into a vein) antibiotics, followed by surgical probing of the duct.

When to Call the Doctor

If your baby’s eyes tear excessively but show no sign of infection, call your doctor or a pediatric ophthalmologist (eye specialist). Early treatment of a blocked duct may prevent the need for surgery.

If there are signs of infection (such as redness, pus, or swelling) or if a mass or bump is felt on the inside corner of the eye, call your doctor immediately because the infection can spread to other parts of the face and the blockage can lead to an abscess if not treated.

Treating Blocked Tear Ducts

Kids with blocked tear ducts often can be treated at home. Your doctor or pediatric ophthalmologist may recommend that you massage the eye several times daily for a couple of months.

Before massaging the tear duct, wash your hands. Place your index finger on the side of your child’s nose and firmly massage down toward the corner of the nose. You may also want to apply warm compresses to the eye to help promote drainage and ease discomfort.

If your baby develops an infection as a result of the tear-duct blockage, the doctor will prescribe antibiotic eye drops or ointment to treat the infection. It’s important to remember that antibiotics will not get rid of the obstruction. Once the infection has cleared, you can continue massaging the tear duct as the doctor recommends.

Surgical Treatments

If your baby still has excess tearing after 6 to 8 months, develops a serious infection, or has repeated infections, the doctor may recommend that the tear duct be opened surgically. This has an 85% to 95% success rate for babies who are 1 year old or younger; the success rate drops as children get older. Surgical probing may be repeated if it’s not successful right away.

The probe should be done by an ophthalmologist. Probes are done on an outpatient surgery basis (unless a baby has a severe infection and has already been admitted to the hospital) under general anesthesia.

The ophthalmologist first will do a complete eye exam to rule out other eye problems or types of inflammation that could cause similar symptoms. A dye disappearance test may help determine the cause of the problem. This involves placing fluorescein dye in the eye (a harmless orange colored dye)and then examining the tear film (the amount of tear in the eye) to see if it’s greater than it should be. The doctor may wait to see if dye has drained properly by having the child blow his or her nose and then checking to see if any of the dye exited through the nose.

A surgical probe takes about 10 minutes. A thin, blunt metal wire is gently passed through the tear duct to open any obstruction. Sterile saline is then irrigated through the duct into the nose to make sure that there is now an open path. There’s very little discomfort after the probing.

If the initial surgical probing is unsuccessful or if a child is older or has a particularly difficult blockage, the doctor may recommend another surgical treatment. One option is called silicone tube intubation, in which silicone tubes are placed in tear ducts to stretch them. The tubes are left in place for as long as 6 months and then removed in another short surgical procedure or in the doctor’s office, depending on the type of stent used.

Another treatment is balloon catheter dilation (DCP). In DCP, a balloon is inserted through an opening in the corner of the eye and into the tear duct, then inflated with a sterile solution to expand the tear duct. The balloon is then deflated and removed.

Both of these procedures are fairly short but require that a child be put under anesthesia. Both are generally successful, with an 80% to 90% success rate in younger kids.

It may take up to a week after surgery before symptoms improve. Your doctor will give you antibiotic ointment or drops along with specific instructions on how to care for your child.