The thought of your little one having an operation can be very stressful, and we understand that. As a parent, you probably have a thousand thoughts racing through your mind, the underlying one being “ will my baby be okay?” This article presents a few tips and pointers to help make the experience as comfortable as possible for the child and the family.

As a Mum or a Dad, the thought of surgery might be more frightening to you than to your toddler. Remember, that’s perfectly normal. Take time to understand why surgery is the best option for your child. Have a conversation with your child’s surgeon, and ask them all the questions you have. Address your fears and try to get a realistic picture of your child’s clinical condition from your doctors. Try to understand what the surgery can achieve and what it cannot. While it may seem scary at first to talk about the risks involved, having a clear picture of what the procedure entails will help you deal with your anxiety and care for your child better. Once the decision to operate has been made, keep a positive attitude towards surgery. Children can tell when their parents are worried, and they tend to reflect their parents’ fears.

Once you have understood the clinical scenario, have a plan in place. Make sure that you and your spouse/partner are on the same page about the surgery. Establish a support system to help you while your child is in the hospital or confined to home. If you have other children as well, figure out before hand how you will care for them during this period. Remember to explain to them that their brother or sister is going to have an operation. Being honest with them will help prevent their being fearful of their own health and safety.

Most procedures require your child to be fasted for 4 to 6 hours. This means that your child may be hungry and consequently irritable just before the procedure. Try to stay as calm and patient as you can. Use an age appropriate method to distract your child. Remember not to feed your child unless your surgeon explicitly tells you to do so. Even a little bit of milk or food in your child’s stomach can make it too risky to carry out the procedure.

A. Preparing your toddler: your toddler is anxious about being away from you, even for a short time. S/he probably thinks that the operation and the injections are punishments for something s/he did. (The favourite threat of Indian parents to get their kids to behave- “I’ll tell the doctor to give you an injection”- only makes things worse). You need to reassure your toddler that everything is going to be okay. Familiarise him/her with the medical team and talk about them in positive terms. Be honest about what the little one should expect- saying things such as” they’re not going to give you an injection” when they are can have a negative psychological impact on your child. Try telling them, “the injection hurts like an ant bite, but not much more than that. You’re strong enough to take it.” Stay calm and composed because your toddler draws strength from you. Allow him/her to choose a toy or a book to bring to the hospital . Stay positive, and your child will too.

B. Preparing your pre schooler: your pre schooler is probably afraid that the surgery will hurt or that it will cause injury. At that age, children worry about their own safety. They may also think the surgery is a punishment, especially if they have been threatened with doctor visits or injections for bad behaviour in the past. Explain the process to him/her a few days in advance. Choose your words carefully because children can misunderstand easily. For example, telling them that the doctor is going to cut something may make them fear violence. Instead try telling them that the doctor is going to repair something for them. Let them know that they will not feel any pain because they will be sleeping while the doctor works and the procedure will be over before they wake up. Reassure your child that surgery could happen to anybody and there’s nothing he or she did to cause it. Try role playing with your child. It will help you identify any misconceptions or fears your child has.

C. Preparing your school going child: a school age child may feel confused about undergoing surgery. They may hear your conversations about the surgery but have their own understanding of what is being said. They may feel they have no control over the situation, which may make them angry or quiet. Try to be as supportive as you can during this period. Talk to your child and encourage him/her to ask questions. Explain the process honestly and hide nothing. Encourage your child to ask the medical team the questions you cannot answer yourself. You may want to involve his/her best friend in keeping your child’s spirits up.

D. Preparing your adolescent: your teenager will be worried about surgical scarring and his/her appearance after surgery. He/she may also be concerned about independence and control. Involve your teenager in decision making about the surgery and ensure that all his/her questions are answered. Have him/her speak to the doctor in your absence if necessary. Be honest about the procedure and encourage him/her to learn about the medical condition if he/she wants to. Allow your teen to express his/her feelings about the procedure through a private journal or in anyway they may feel comfortable. Try to assess what understanding they have about the surgery and identify any points of confusion or concern.

Your child’s surgery can be a stressful time for his/her siblings. A sibling may feel left out or neglected while your child is in hospital. He/she may be afraid that he/she will have to go through the same thing next. There may be feelings of jealousy because of the attention being given to the patient. This may manifest in the sibling “acting up” or being unusually quiet or cranky. Remember to reassure the sibling that they’re going to be safe. Involve them in the preparation and the process of the surgery. Encourage the sibling to support his/her brother or sister through the surgery. Involve the sibling in role play so that you can understand their thinking about the situation. If the sibling is being sent away to a relative or is going to be cared for by somebody else for the time, reassure him/her that it is not a punishment for something he/she did. Try to make the sibling feel equally loved and involved.

As I said before, your child’s surgery is probably stressing you out. Remember to take care of yourself through the process, because your children depend on you. It is natural to have feelings of fear or anxiety. Some parents have even expressed feelings of guilt. Talk to your loved ones about how you feel. Try to clear any misconceptions about the surgery by speaking to your doctor. Stay away from superstition and pseudoscience. Remember that your child’s condition is in no way your fault, and by seeking treatment for him/her, you’re doing your best.

You’re an amazing parent, and you’re already doing a fantastic job to get your family through this. Don’t let anyone tell you otherwise!

With advancing technology, ultrasound machines allow doctors to see your unborn baby’s organs more clearly. Often times, babies are found to have enlarged kidneys while still in the uterus- your doctor may use the term “hydronephrosis”, i.e, “antenatal hydronephrosis” or “foetal hydronephrosis.”

Hydronephrosis essentially means that there’s urine backed up in your baby’s kidneys. It may be unilateral, meaning that the kidney on only one side is affected, or bilateral, meaning that both kidneys are affected. The causes for hydronephrosis in the unborn child are numerous, and the treatments vary based on the cause.

The urinary tract consists of the kidneys, the ureters, the urinary bladder and the urethra. The primary function of the kidneys is to manufacture urine by filtering out solutes and waste products from the blood. The urine from each kidney is transported to the bladder by a fine muscular tube called the ureter. The urinary bladder stores urine and then throws it out via the urethra.

When your doctor assesses your baby’s urinary tract, some of the things he/she looks for are the following

• Are both kidneys are present?
• Are both kidneys are positioned normally?
• Is there any enlargement of one or both kidneys? (Is there any hydronephrosis ?)
• Are the ureters dilated?
• Are there any cysts in the kidneys?
• Can the bladder be seen to fill and empty?
• Is there an abnormality in any other structure or organ?
• Is there enough fluid around the baby?

The most common problem detected in the urinary tract of an unborn baby is hydronephrosis. The condition of the rest of the urinary tract affords a clue to the cause of hydronephrosis.

In India, paediatric surgeons and paediatric nephrologists are trained to treat conditions of the kidneys in children. During pregnancy, your doctor may ask you to follow up more closely with frequent ultrasounds. The ultrasound findings will offer your doctor some clues about how severely the bay has been affected. Once the baby is born, further investigations are usually needed to determine the course of action. Typically, these investigations include an ultrasound, a special xray called a voiding cystourethrogram ( VCUG; also commonly called a micturating cystourethrogram or MCU) and sometimes, renal scintigraphy studies. Depending on the findings of these tests, treatment varies from immediate surgery to simple observation. Oftentimes, low dose antibiotics are recommended to prevent urinary tract infection in the baby. In all cases, strict follow up and close monitoring of the urinary system is required.

Relax. Remember that your baby is growing, and so is its renal system. As of today, ante natal therapies have not been proven to be helpful in changing long term outcomes for hydronephrosis. Familiarise yourself with the team that is going to care for your baby once it arrives. Have a detailed discussion about the team’s plan for the baby. Be prepared to stay in the hospital for a few days after you deliver. Talk to your doctors about all your concerns for yourself and for your baby. Care for yourself as your gynaecologist has advised, and keep a positive attitude.

Minimal access is the buzzword in paediatric surgery. It essentially means performing a procedure without cutting open the body wall. While the principles and the basic steps of each surgery remain the same, special instruments are used which reach the organ in question via tiny, key hole incisions or through a natural orifice. Minimal access surgery includes:

Endoscopic surgery, which is a procedure performed inside a hollow organ (eg the urethra, the urinary bladder, the stomach, the ureters, even the kidney) through an optical instrument inserted through a natural orifice such as the urethral meatus or the mouth.

Laparoscopic and thoracoscopic surgery – in this type of surgery, long, fine instruments are inserted through the body wall to reach the organ that needs surgery. The surgeon uses a fine telescope with a camera to look inside. The term laparoscopic means that the surgery is done in the abdomen while the term thoracoscopic means that the surgery is being done in the chest.

Robot assisted surgery: this is the latest advancement in minimal access surgery in children. In this type of surgery, the surgeon uses robotic arms to perform key hole surgery. The robot is completely controlled by the surgeon, and all surgical decisions are made by the surgeon. The robot overcomes the most serious limitation of laparoscopy, which is freedom of movement. Laparoscopic instruments are like long sticks which are manoeuvred by the surgeon on one end to manipulate the organ on the other end. Robotic instruments have a complex assembly of miniature pulleys and joints at the tip which allow nearly as much movement as the human wrist. This makes it easier for the surgeon to perform complex reconstructive procedures through key hole incisions.

The list of procedures that can be performed with minimal access is exhaustive. In today’s world, nearly every type of surgery has been performed with minimal access. Whether or not a patient can undergo such a procedure depends on a number of considerations. For instance, many minimal access procedures require the body cavity to be filled with a gas, usually carbon dioxide. Patients with a compromised heart or severely affected lungs may not be able to withstand this carbon dioxide. Extremely small patients such as premature infants, besides having very delicate physiology, may be physically too small to accommodate the minimal access instruments. The feasibility of removing a tumour by minimal access depends on the size, location and behaviour of the tumour. In general, a minimal access procedure takes more time to perform than an open procedure.

However, the advantages of minimal access are not insignificant. This technique minimises the scarring in the muscles of the body wall, which is advantageous in the growing child. Since the incisions are smaller, the pain and the consequent need for painkillers are greatly reduced. Although operative time increases, recovery and return to routine activities are hastened. And of course, the cosmetic outcome of a keyhole incision is much better than that of a large incision.

All in all, a patient who is a candidate for minimal-access surgery should receive one. That said, the technique should not be misused.

Tongue tie, or ankyloglossia, is a condition where the bottom of the tip of the tongue is tethered to the floor of the mouth by a band of tissue. As a result, the movements of the tongue are restricted. Individuals with tongue tie typically are unable to touch the upper incisors with the tip of their tongue, move their tongue from side to side, or protrude the tongue beyond the lower teeth.

In most cases, a parent notices the condition when the child does not stick his/her tongue out, or when the tongue appears notched every time the child tries to protrude it. Signs that your child may have a tongue tie are:

In newborns and infants:

1.Difficulty in breast feeding: a tongue tie may be preventing your baby from latching on to the breast. A baby needs to protrude his/her tongue over the lower gums in order to suck. If unable to do so, the baby may chew on the nipple instead of sucking, leading to pain for the mother and inadequate nutrition for the baby.

However, the majority of infants with tongue tie are able to feed normally.

2. Difficulty in swallowing

3. Difficulty in developing certain consonant sounds: when babies begin to babble around 4-6 months of age, they string together consonant and vowel sounds such as “a-ga” or “a-ba”. Their repertoire of consonant sounds increases, and between the age of 12 and 18 months, they form their first words. Babies with tongue tie may not be able to make certain sounds.

Toddlers and older children:

1. Speech difficulties: Delayed or inappropriate speech development is one of the main symptoms that leads to the discovery of tongue-tie. Restricted tongue movement can make it difficult to pronounce sounds such as “t”,”d”, “z”, “s”, “th”, “r”, and “l”.

2. Oral hygiene and dentition problems: Difficulty in removing food debris from the teeth or palate can lead to cavities and gingivitis. Continuous pressure on the lower teeth can lead to formation of a gap between the lower incisors.

3. Difficulty with licking ( an ice cream cone or such), difficulty protruding the tongue.

4. Psychosocial impact

The treatment for tongue tie is a short surgery that involves cutting the band that tethers the tongue. In adults and older children, the procedure can be done with local anaesthesia, but infants, toddlers and younger children require general anaesthesia. Rarely, a more extensive procedure called a frenuloplasty may be required. If detected early, it is preferable to perform the procedure at about 6 months of age, which is the time that the child is developing the ability to pronounce different consonant sounds. The surgery needs be done in a younger infant if the condition interferes with feeding. A child may still require speech therapy after surgery to help develop normal speech. This is especially true in cases where the condition has come to light after language has already developed.

There is minimal wound care required after a simple tongue tie release. Good oral hygiene is usually all that is required

Daytime and nighttime wetting are among the more frequent problems that we see in school-aged children. While some children find it hard to toilet train in the first place, others may have leaks and accidents months or years after they have successfully toilet trained. We understand that daytime wetting is stressful for the parent, but it is far more stressful and embarrassing for the child. Children don’t want to wet- it’s just that they can’t stay dry. Unless addressed, daytime and nighttime wetting can have lasting psychological and behavioural impacts on the child.

A child may be wetting for a number of reasons. If your child was born with a condition such as an anorectal malformation, a urologic anomaly or a spinal dysraphism, achieving continence may be a challenge for him or her. Therapy may include surgical procedures that help achieve “social continence”, which means the child can achieve a level of dryness that allows him/her to participate in regular activities with other children at school and outside.

However, the vast majority of children who wet have no anatomic abnormality. It is important to understand that bladder control in a child is different from bladder control in an adult. When children toilet train, their pelvic muscles learn to relax and contract in a coordinated manner. During this phase, children can develop holding behaviours which either prevent them from emptying their bladders completely or prevent them from going before it is too late. Incomplete emptying of the bladder can lead to urinary tract infections (UTIs) that further compound the problem.

Children who have urine leaks are also usually constipated. The pelvic floor nerves and muscles that control urine are closely related to those that control stool. Hence, a child who holds urine also likely holds stool. It is important to pay attention to the posture of the child while passing urine or stool. The child must be seated comfortably on the toilet seat to enable the pelvic floor muscles to relax. It is advisable to use a footstool to support the child’s feet while seated on the toilet so that the torso is relaxed and the hips and knees are parallel to each other. A child-sized toilet seat is also highly recommended to ensure that the child’s pelvis is relaxed. Even little boys may benefit from sitting on the toilet to urinate in the early part of toilet training. When seated on the toilet, the child’s knees must be kept apart. Pants must be pulled down all the way to the ankles. To pass urine, the child must be at the toilet for at least 30 seconds to a minute. It may be necessary to engage the child with a book or a conversation so that he/she sits on the toilet for adequate time. Many Indian households have an Indian-style toilet. A small child will not be able to squat on the pan. These children may develop a habit of passing stool and (in girls) urine in the standing position which can lead to constipation and wetting. In that case, it is advisable to use a “potty” until the child is tall enough to squat on the pan.

Attention to your child’s diet and fluid intake is also necessary. Many school-age children learn to avoid drinking water so as to avoid going to the toilet, especially while at school. This compounds the problem in more ways than one. A decreased fluid intake predisposes to urinary tract infection (UTI) which causes the bladder to become irritable. Poor fluid intake also leads to the formation of hard stool resulting in constipation. The presence of a loaded bowel in the pelvis further makes it difficult for your child to effectively empty his or her bladder with adequate control. Avoidance of all foods that can constipate the child- which includes refined flour in bakery products and high sugar content foods- is necessary.

Your paediatrician and paediatric surgeon will need to have a detailed conversation with you and also run a few tests to decide what the cause of wetting in your child is. Most certainly, they will be looking for evidence of a UTI and an anatomic anomaly that could cause incontinence. They would ask you to observe details of your child’s voiding habits, including how frequently he/she voids, how frequently he/she wets, and whether you can identify anything that might be precipitating accidents. They may also have to perform invasive tests such as a VCUG or a urodynamic study. Further therapy will be determined by their findings. in many cases, simple behavioural changes and timed voiding can relieve children of the problem. Do not restrict your child’s fluid intake unless your doctor asks you to do so.

Night-time wetting usually resolves later than daytime incontinence. Isolated nighttime wetting (nocturnal enuresis) in the absence of daytime wetting can be a manifestation of underlying emotional issues in the child, although it is not always so. Teasing by siblings and peers can worsen the problem. Nocturnal enuresis can be treated with behavioural modification and pharmacologic therapy. Use of bed-wetting alarms, voiding at bedtime and limiting fluid intake two hours before bedtime are some common interventions that have proven useful. Patience while dealing with the child is paramount, but the results of therapy are good.

If your child is wetting, do not hesitate to seek help. Timely intervention by your doctor will not only help resolve the issue but will avert any long-term impact of the incontinence.

Introduction

Intussusception is a common condition in childhood wherein one segment of the intestine telescopes into the other. It is most common in the first two years of life but it can affect all pediatric ages. It is a surgical emergency in children, and with timely intervention, the outcomes of treatment can be excellent.

Intussusception most commonly occurs as a consequence of a viral infection. In older children, a diverticulum of the intestine is often the instigating factor. Other lesions such as polyps or masses are the underlying cause in a minority of childhood cases. Such lesions are called pathological lead points. They are usually picked up during investigation for the intussusception and their presence or absence determines further therapy.

When one loop of bowel telescopes into the other, the bowel wall begins to swell, leading to blockage of the bowel lumen. Gradually, the blood vessels supplying the bowel wall get compressed. The bowel wall becomes weak in some areas making it susceptible to rupture. Complete occlusion of the blood supply can lead to bowel gangrene. Timely intervention is necessary to avoid these complications.

The most common symptom of Intussusception is crampy abdominal pain with or without vomiting. Between episodes of pain, the baby may appear surprisingly well. Many children have had symptoms of a viral infection or diarrhea in a preceding couple of days. During an episode of pain, the child typically draws his/her legs over the abdomen while crying. Another classic symptom is the passage of blood and mucus in stool, described as “red currant jelly stool”. Along with these symptoms, your doctor’s findings on examination of the child will lead to the suspicion of Intussusception. The diagnosis is confirmed by a radiological investigation, which is usually ultrasonography.

The therapy offered by your paediatric surgeon will depend on a number of clinical and anatomical factors. Generally, the surgeon would follow one of two approaches a) enema reduction and b) surgery.

1. Enema Reduction:

In recent years, this non-invasive therapy for Intussusception has become the first line of treatment in many cases. In this therapy, a paediatric surgeon uses radiological guidance to reduce the Intussusception ( which means to free the bowel) by instilling fluid rectally. The use of ultrasound to guide the procedure is popular because it is free of radiation risk.

In general, it is difficult to do the procedure after 48 hours of the onset of symptoms. Whether or not enema reduction can be attempted depends on the surgeon’s clinical judgement. Even in the best of hands, there remains a small but real risk of bowel perforation during enema reduction. Therefore, your surgeon will always have the child ready for surgery before attempting an enema reduction. This is because enema reduction can fail, or can be complicated by a rent in the intestine. In that case, the child needs to be operated on immediately, to minimise damage.

2. Surgery:

this was the classic treatment for Intussusception, before the advent of enema reduction techniques. Even today, a paediatric surgeon will decide to proceed straight to surgery, especially if the symptoms have been present for more than two days, the child’s bowel seems obstructed, the anatomy of the intussusception is not amenable to enema reduction, or the surgeon suspects that there may be a mass or lesion causing the intussusception and which needs to be removed.

The surgery may be limited to simple manual reduction of the intussusception or may require more extensive procedures such as the removal of a part of the bowel. If any bowel has been removed, it will be sent to a histopathologist for examination. This is to detect any underlying illness that will require more extensive therapy.

Intussusception can recur after therapy and the surgeon will continue to remain vigilant after an enema reduction or surgery. The risk of recurrence is 4-10% after enema reduction and 3-5% after surgery. That is to say that more than 90% of children will not have a repeat episode. There is nothing that can really be done to prevent an intussusception. Attention to food hygiene is all that can be recommended.