APPENDICITIS

Definition: Inflammation of the appendix in the large intestine.

Note: Whenever a child complains of severe abdominal pains, it is likely that the parent is concerned that the child may have appendicitis. If abdominal pain develops suddenly and the child continues to complain, the doctor should be contacted. It is impor- tant that the diagnosis of this condition be established early to avoid having the appendix rupture, which causes more serious problems for the child.

1. How did this condition develop in my child?

The appendix is a leftover of development where the small and large bowel are joined in the right lower quadrant of the child’s abdomen. It is hollow, and it opens into the large bowel. The opening is small and susceptible to being clogged by a stool ball (called a fecalith), or it can swell shut when the child has a viral illness somewhere else in the body. The opening of the appendix is surrounded with the same lymphoid tissue that swells in your child’s neck when he or she gets a viral illness. The appendix normally has bacteria in its hollow center that are evacuated with the stool. If the opening is blocked, however, the bacteria continue to grow but cannot escape. Pressure builds up, and the bacteria can invade the wall of the appendix, weakening it. If left untreated, the appendix can “rupture,” spilling the infection into the wider abdomen.

2. Are there further tests to be done to more fully establish the diagnosis?

The most common test is a CT scan of the abdomen and pelvis. Sometimes a sonogram can also identify appendicitis. There is no single test (or combination of tests) that is 100 percent accurate, so the decision to perform an appendectomy is based on a combination of blood and urine tests, radiology images like a CT scan, and examination by an experienced surgeon. Sometimes, if the diagnosis is in doubt, your child may be admitted to the hospital for a period of observation and/or repeat testing.

3. What is the treatment for this condition?

The definitive treatment is to remove the appendix with an operation. This may be done through an incision in the right lower quad- rant of the abdomen or with a laparoscope (which uses three small incisions, one of which is in the belly button). If the appendix has already ruptured and a pus pocket (abscess) has formed around it, the best treatment may be to drain the pus and treat the child with antibiotics first and remove the appendix later (sometimes six weeks later). Many children require intravenous fluids and antibiotics for several hours prior to the operation so they tolerate the anesthesia better.

4. What complications can occur as a result of this condition if left untreated?

The complication that everyone worries about is rupture. If a child has a nonruptured appendix removed, he or she can usually be discharged home without antibiotics in one to two days after the operation. If the appendix has ruptured, however, the child will need five to seven days of intravenous antibiotics after the operation and additional oral antibiotics at home. Even then, children are at much higher risk for abscess formation (usually forms about a week after the appendectomy), which may require drainage with another procedure.

5. What, where, and by whom should the surgery to correct this condition be performed?

The appendectomy is usually performed by a pediatric surgeon in smaller children and by a pediatric or adult general surgeon in teenagers. It must be done in a full service hospital, not a day surgery center.

6. If surgery is necessary, what are the potential complications that can occur?

Local infections in the skin incisions can occur. This appears as bright redness extending more than one-half inch from the edges of the incision or pus draining from the incision. Local infection is treated by removing the outer layer of stitches to allow the area to drain and by antibiotics.

     An abscess (a pus pocket formed deep in the abdomen) can occur about a week after an appendectomy for ruptured appendicitis. Formation of an abscess is rare after an appendectomy for nonruptured appendicitis. The abscess is almost always discovered prior to the child going home. If the child still has fever, severe pain, and/or persistently abnormal blood tests greater than one week after the operation, a repeat CT scan of the abdomen and pelvis may be done to check for an abscess. If one is found, one of three treatments will likely be recommended: continued IV antibiotics (for smaller abscesses), drainage by the radiologist using a CT scan for guidance (with the child asleep, a small catheter is inserted into the abscess and left in place until it resolves), or (rarely) another operation for drainage of abscesses that cannot be reached safely by the radiologist.

7. When do you wish to see my child again regarding this condition?

If the appendix did not rupture, one visit to the surgeon two to three weeks after discharge home is sufficient. Most children will be allowed to return to sports or physical education classes after this visit. If the appendix ruptured, an additional visit may be necessary after all antibiotics have been completed. 

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ANEMIA

Definition: A condition of reduced red blood cells in the circulatory system.

Note: This is always a worrisome condition in childhood. Anemia can make children sluggish and decrease their capacity to perform. There is no reason why the cause of anemia cannot be fully established and appropriate treatment rendered if necessary.

1. What causes this condition to occur in my child?

Anemia occurs when there are not enough red blood cells to meet the needs of the child. Red blood cells carry oxygen to the various parts of the body. There are three reasons why a child may become anemic.

The first cause is bleeding. If the child is losing red blood cells from the body, whether it is from chronic nosebleeds or from bleeding in the gastrointestinal tract, eventually the red blood cell count will go down, and the child could become anemic.

     The second reason why a child may become anemic is if the body is unable to produce sufficient amounts of red blood cells. The most common reason in childhood is a lack of sufficient iron in the diet. This occurs most frequently in children between the ages of one and two who have had a diet made up primarily of cow’s whole milk. If the child is not getting sufficient iron in the diet, then the child is not able to make sufficient red blood cells. This can result in severe anemia. 

     The third reason why a child may become anemic would be if the red blood cells that the child produced do not survive in the body for a normal period of time. Normally, once red blood cells are made, the red blood cells will last in the body for approximately three months. There are a number of conditions that could cause the red blood cells to break down earlier than normal. In general, these are called hemolytic anemias. There are many different types of hemolytic anemia. Some types are inherited and are not correctable. Some types occur after certain viral illnesses and will eventually get better.

2. What tests are needed to better define the condition?

The first step is to measure the amount of hemoglobin and red cells in the body. Then, the physician or the laboratory technician will look at the red blood cells under the microscope. This will often give the physician a clue as to what is causing the anemia.

     The physician then might order a number of different tests to deter- mine the diagnosis. For instance, if the physician feels that the child may be losing blood, the physician may order special tests on the stool to look for any signs of blood. The physician also might want to measure the amount of iron in your child’s body. There are many tests that can better define the reasons for anemia.

3. How is it treated, and is it correctable?

The treatment for anemia depends on its cause. If the anemia is due to bleeding, then the cause for the bleeding must be determined, and corrective action will be taken. If the anemia is due to an insufficient amount of iron in the diet, then the patient will be placed on supple- mental iron, and often a change in diet is warranted. Some types of anemia are not correctable, though the most common forms of anemia are easily correctable.

4. Are there any potential side effects of the treatment?

There is always the possibility of side effects with any treatment, but in general, the treatment of anemia is well tolerated. Certain oral iron preparations may cause some temporary discoloration of the teeth or some belly pains or some constipation. Often, the physician can change the type of iron supplementation to meet your child’s needs.

5. What symptoms will my child have as a result of the condition?

In general, the symptoms of anemia are not seen in childhood until the anemia is fairly severe. The signs of anemia generally include fatigue and lack of energy.

6. Do we need to consult a hematologist (blood disorder specialist)?

Most pediatricians are able to diagnose and treat the more common causes of anemia in childhood. Sometimes the pediatrician will request a consultation from a pediatric hematologist for advice in treating anemia.

7. How often will my child need to be tested in the future to see if the condition is improving?

This depends on the cause of the anemia. If the anemia is due to iron deficiency, then the child will be tested several times in the first year or two to make sure that the condition is improving. In other cases of anemia, the scheduling for repeat testing will depend on the cause of the anemia.

8. When do you wish to see my child again regarding this disorder?

The frequency of visits to the doctor for the treatment of anemia will depend upon the cause of the anemia. In general, several trips to the doctor will be required in the first six months to a year if the anemia is due to iron deficiency. 

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ACNE

Definition: A chronic inflammatory disease of the sebaceous (oil) glands characterized by pimples and pustules occurring primarily on the face, back, and chest.

Note: There is no need for a teenager to grow up with severe scarring due to acne. Today there are good treatments that can minimize the long-term cosmetic ill effects caused by this condition.

1. What causes this condition to occur in my child?

Acne is triggered by hormone changes in adolescence. Children with acne have oil (sebaceous) glands that tend to produce more sebum (oil). They also have pores that tend to plug more easily. These plugs are made of sebum and dead skin cells. When the pore becomes plugged, bacteria are trapped in the pore, and the pore becomes inflamed, resulting in a pimple. Genetics also plays a role, and some families are more prone to develop acne than others. Unlike what many people think, acne is not due to dirt or not washing your face enough.

2. Is there any way to predict how bad it will get?

Signs that a child may develop more severe acne include earlier age of onset, family history, and being male. As a general rule, males tend to have more severe acne than females. The earlier acne starts (i.e., before age thirteen), the more severe it may be. Children prone to develop bad acne often have family members who had severe or scar- ring acne. The presence of deeper, tender, cyst-type acne lesions or scarring is a sign of more severe acne, and children with these signs should seek treatment early.

3. What can I do to prevent it from getting worse?

Face washing is not enough. The best thing you can do is to start treatment early. In general, it takes eight weeks for any acne treatment to start working, so if you do not see any improvement from your child’s over-the-counter acne treatment after eight weeks, you may need to consider prescription treatment. Your child should avoid squeezing pimples; this makes the pore more inflamed and increases the risk of scarring. Children should also not scrub their faces harshly or use abrasive cleansers, since this can inflame the skin more. Things that touch or fit tightly against the skin can plug pores, so your child should keep his or her hair, hands, head- bands, caps, hair products (gels, hair sprays, etc.), and sports gear off of the face, forehead, shoulders, and back as much as possible.

Products (moisturizers, sunscreens, cosmetics) used on the face and body should be oil free and noncomedogenic (proven not to cause acne). If possible, teens should avoid jobs in places such as fast food restaurants or auto shops, where the skin will be in contact with oil or grease that can aggravate acne.

4. Does diet affect acne?

This is an area of much debate. In general, there are no specific foods that are proven to worsen acne. It is always a good idea to limit junk food as much as possible, but this may not have any bearing on your child’s acne. If there is one particular food that consistently seems to worsen your child’s acne, then avoiding that food may help.

5. What skin cleanser should be used?

A mild, nonabrasive, nondrying cleanser applied with clean hands or a clean washcloth and warm (not hot) water once or twice daily is recommended. For acne, medicated cleansers containing either benzoyl peroxide or salicylic acid can be used, but they may cause skin irritation or dryness, especially if used in combination with prescription acne medications. Astringents are usually not needed, but may be helpful for teenagers with very oily skin.

6. What about Retin A, benzoyl peroxide, and topical antibiotics?

Retinoids (Tretinoin [Retin A, Renova, or Avita], adapalene [Differin], and tazarotene [Tazorac]) are vitamin A–derived medica- tions and are some of the most effective acne medications that we have. They come in cream or gel forms. Retinoids gently exfoliate the dead skin cells and prevent the first step of acne formation, which is the plugging of the pores. By keeping the pores open, pimple formation is prevented. Retinoids are effective for all types of acne lesions. Like most acne medications, they are best used on a consistent basis on the entire acne-prone area (rather than spot-treating individual pimples only). Using the medication on all acne-prone areas helps to prevent future pimples from forming. Retinoids work well alone or in combination with other therapies but should be applied sparingly and no more than once daily to limit dryness and irritation, which are common side effects. Because they can make the skin more sensitive to the sun, sunscreens and sun protection should be used. They should not be used by teens who are pregnant.

     Benzoyl peroxide is another standard acne therapy. Like the retinoids, it is effective for all types of acne lesions and may be used alone or in combination with other therapies. It has antibacterial as well as antiplugging effects. Benzoyl peroxide is available as a wash or as a leave-on topical (a cream or gel applied to the skin). Dryness is a common side effect and can usually be prevented by applying a gentle moisturizer and stopping the medication for a few days. Some individuals may develop a skin allergy to this medication, so if severe redness or irritation develop, you should consult your child’s doctor. Benzoyl peroxide may bleach clothing, towels, or bedding.

     Topical antibiotics decrease the acne-causing bacteria (Propionibacterium acnes) on the skin but have no effect on plugging of the pores. They work best for inflammatory acne (red bumps, pus bumps, and cysts). It is best not to use topical antibiotics alone as a single therapy. Using topical antibiotics in combination with a retinoid or benzoyl peroxide improves the effectiveness of the medications and makes it less likely that the acne bacteria will develop resist- ance to the antibiotic over time.

7. What about oral antibiotics?

For teenagers with severe inflammatory acne that does not respond to topical therapy alone, oral antibiotics can be very helpful. As with topical antibiotics, oral antibiotics do not prevent plugging of the pores, so they are not helpful for non inflamed acne lesions, such as black- heads, and are best used in combination with a retinoid or benzoyl peroxide. They should not be used alone as the only acne therapy.

     The most commonly used oral antibiotic is the tetracycline family (tetracycline, doxycycline, or minocycline). In general, oral antibiotics are used for a period of several months until the acne is improved and can be controlled with topical medications alone, but use for longer periods of time may be required for some individuals. Courses of less than one month are generally not effective.

      These medications are usually well tolerated but can cause nausea if taken on an empty stomach. They can also cause sun sensitivity, so sun protection and sunscreen use is important when taking these medications. For females, taking any oral antibiotic can increase the likelihood of developing a vaginal yeast infection; signs of this include vaginal itching or irritation and a whitish discharge. Oral tetracyclines should not be taken if your child is pregnant. It is common for teenagers to prefer the convenience of oral antibiotics, so they may be tempted to stop their topical medications. For best results, it is very important that they continue using their other medications as prescribed.

8. What about Accutane (oral isotretinoin)?

Oral isotretinoin (Accutane) is the most potent medication currently available for acne. Because this medication can cause birth defects if taken by a pregnant female and because laboratory monitoring is required, this medication should be reserved for severe acne only. It is most effective for severe cystic or scarring acne that has failed to respond to at least three months of maximal combination therapy (oral antibiotic plus a topical retinoid and another topical medication). All patients must be entered into a registry by a physician registered to use this medication, and females must use two methods of birth control to prevent pregnancy. It is not effective for females with hormonal types of acne, such as acne related to polycystic ovary syndrome.

9. When should we consider a dermatologist?

If your child’s acne has not responded to over-the-counter therapy or to the medications prescribed by his or her primary care physician, consultation with a dermatologist would be recommended. If your child has severe or scarring acne, if severe acne runs in your family, or if your child develops significant acne at a very young age, you may want to consider seeing a dermatologist sooner.

10. When do you want to see my child again regarding this condition?

Because most acne therapies require a minimum of eight weeks to start working, follow-up two to three months after starting therapy is generally recommended. Earlier follow-up may be needed if prob- lems, such as irritation or other medication side effects, develop. A temporary worsening of the acne four to six weeks after starting treatment is not uncommon and is considered normal; medications should be continued, and the acne typically gets better over the next several weeks. 

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UNDESCENDED TESTICLE(S)

Definition: When one or both testicles do not descend completely into the scrotum.

1. What caused this condition?

There are many theories as to what causes an undescended testis. Some include decreased intraabdominal pressure during the third trimester of pregnancy to push the testis from the abdominal cavity to the scrotum. Some feel that there may be a decreased amount of male hormone such as testosterone during the descent of the testis. However, there is no unifying theory or answer to the cause of undescended testes.

2. Is there a danger of sterility or any other problem as a result of this condition?

If the testicle is undescended only on one side, the fertility rate is the same as a normal population. If there is an undescended testis on both sides, the most current data suggests that fertility is only approximately 65 percent to 70 percent. Testis cancer risk is elevated in adult men who have a history of an undescended testis.

3. Will an operation be necessary to correct this condition and, if so, when?

If the testicle is not in the scrotum by approximately nine months of age, then an operation is necessary to position the testicle in the scrotum where it will grow and develop normally. If the testicle is nonpalpable (cannot be felt on examination of the body), then the operation is usually performed at approximately six months of age.

4. When do we need to consult a surgeon?

Generally if a child has an undescended testis, we would like to see the child at a time convenient for the family. Any time between two and six months of age is a good time to have a surgeon initially evaluate the situation.

5. Are there any medicines that can be used to help bring down the testicle(s)?

No.

6. Are there any danger signs that I should look for?

Yes. Most boys who have an undescended testis have a small hernia that coexists with the undescended testis. If there appears to be swelling or tenderness in the groin area suggestive of a bulge or hernia, then this would suggest that the surgery should be done immediately, as this type of hernia can potentially damage or cause loss of the testicle. Rarely an undescended testis can twist (testis torsion) and cause swelling and pain.

7. Following discharge from the hospital, when do you wish to see my baby again?

After discharge, we would like to re-examine the baby in two to three months. 

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SEIZURES - NEONATAL

Definition: Convulsive fits or spasms during the first month of life.

1. What is a seizure?

A seizure is a clinical event (episode) that is the result of excessive activity of a group of nerve cells (neurons) in the brain. There are many different types of seizures (staring, turning the body to one side, jerking of the arms and legs, etc.). The type of seizure a baby has depends upon the baby’s age and the part of the brain that the seizure is coming from. Also, the cause of the seizure may determine the type of seizure a baby has.

2. What causes seizures in babies?

Anything that can cause the brain not to work normally can cause a seizure. Common causes in babies include not getting enough blood and oxygen to the brain, bleeding in the brain, infections of the brain, strokes (when the blood flow to a part of the brain is cut off), metabolic problems (such as low blood sugar or calcium), abnormalities in how the brain is formed, inherited problems, or drug withdrawal (such as if the mother used certain drugs or alcohol during the pregnancy especially on a regular basis). There are other less common causes as well.

3. How are seizures treated, and how effective is the treatment?

Treatment depends upon the cause of the seizure. For example, if the blood sugar is too low, giving sugar typically solves the problem. Sometimes it is necessary to give medication to stop the seizures. The more commonly used medications include diazepam (Valium), lorazepam (Ativan), phenobarbital, and phenytoin (Dilantin). The effectiveness of these medicines at stopping seizures is mainly dependent upon the cause of the seizures. Similarly, how long the baby will need to stay on the medication(s) is often dependent on the cause of the seizures.

4. Are there any side effects to the medicines used in the treatment?

Like any medication, there is always the possibility of side effects. In general, these medications are quite safe. The most common side effect is sleepiness (sedation). This will usually go away once the baby gets used to the medication (typically in three to seven days).

5. What potential harm can the seizures have, and can they cause brain damage?

Many times, it is the presence of brain damage (such as stroke, infection, bleeding in the brain, trauma, and malformations of the brain) that cause the seizures. In these cases, it is the underlying problem that causes brain damage, not the seizure. In some instances, however, especially if the seizures are very long (greater than fifteen to thirty minutes), or they are very frequent, they may cause brain damage.

6. What tests do we need to do to establish any possible underlying cause?

What testing your baby may need will be determined by the circumstances around your baby’s seizures. It is likely that your baby will have some blood and urine tests. If it is found that your baby has low blood sugar and giving your baby some sugar solves the problem, then no other testing may be needed. If the doctor is worried about infection, it is likely that he or she will do a spinal tap. If the blood tests are normal and there is not an obvious cause for the seizure, it is likely that your doctor will want to look at your baby’s brain, either with a CT or MRI head scan. Your doctor may also want to get a brain wave test (electroencephalogram or EEG).

7. Do you think that the seizures will recur, and what are the possibilities that my baby will outgrow them? 

Whether or not the seizures will recur is in large part due to the cause of the seizures. Babies that have had lack of blood or oxygen to brain, strokes, trauma, and conditions where the brain did not form normally tend to have seizures that can be hard to stop and often come back later in life. Babies that are normal except for a family history of seizures in early life or that have had low blood sugar or calcium as the cause of their seizures often do very well, and the seizures typically do not come back.

8. Do we need to consult with a neurologist?

This depends on the cause for the seizures. Babies that have low blood sugar or low calcium as the cause for their seizures do not typically need to be seen by a neurologist. When more serious conditions like stroke, trauma, abnormalities in brain formation, or lack of oxygen occur, follow-up with a neurologist is a good idea.

9. Are there any precautions we need to take when we go home, such as connecting my baby to an apnea monitor?

In most cases, unless there are complicating problems (breathing problems, swallowing problems, etc.), there is no need for special monitoring or precautions. Typically, treating your baby as you would any other newborn is all that is needed.

10. When do you wish to see my child again regarding this condition following discharge?

When your baby needs to return for follow-up will be dependent on the cause of your baby’s seizures. Normally, we will see your baby two weeks after discharge from the hospital. If you see a neurologist in the hospital, he or she will arrange for follow-up if needed. Many times, if follow-up is required, he or she will ask to see your baby one to three months after discharge, but again, this will be determined in large part by the cause of your baby’s seizures. 

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