Hydrocele and Inguinal Hernias in Children

Hydrocele and Inguinal Hernias in Children

Hernias and hydrocoeles are the commonest conditions seen by paediatric surgeons as they occur in about 3-5% of children. The cause for both these conditions is the failure of the processus vaginalis to close before or just after birth (see Figure 1).

  • If the processus vaginalis is small, there is a passage between the abdominal peritoneum and the tunica vaginalis of the testis may allow fluid from the abdomen to trickle down and collect as a hydrocoele around the testis. This is called a HYDROCELE
  • If the tract is larger, the bowel or momentum can also go into This is called an INGUINAL HERNIA

Hydrocoeles are harmless and majority spontaneously resolve by 2 years of age or require surgical closure if they persist beyond 3 years of age.

Figure 1: Hydrocele

Figure 2: Inguinal Hernia

Indirect inguinal hernias on the other hand, do not go away and can cause problems to the child especially for the under 1 year-old.

The risks are:

  • Incarceration where the hernia is stuck causing bowel obstruction
  • Strangulation of the hernia where the blood supply to the herniated bowel is cut off causing necrosis and perforation of the bowel
  • The hernia may compress on the blood vessels to the testis at the inguinal ring and cause testicular atrophy (and loss of sperm production) in boys

Image Source: US News

Hernias must be corrected as soon as possible, especially in the under 1 year-old. When the hernia is stuck (incarcerated) or strangulated, they will need urgent reduction or emergency surgery to prevent damage to the bowel or testis.

How to distinguish a hydrocele from an inguinal hernia

  • Age of onset: hydroceles can be seen soon after birth as a non-tender scrotal swelling whereas hernias usually presents early in premature infants but usually within the first 2 years of life in term babies

Image Source: Getty Images

  • Constancy: hydroceles are seen most of the time and often smaller in the mornings and gradually increase in size as the day passes. Hernias on the other hand, comes and goes and often appears when the child cries. It helps if the parent can take a photo to show the doctor
  • Location: hydroceles are usually located are in the scrotum except for encysted hydroceles of the cord (see Figure 3 below) whereas hernias extend can from the inguinal area to anywhere down towards the scrotum
  • Physical exam: one can get above a hydroceles whereas one cannot get above hernias
  • Reducibility: Non-incarcerated hernias can often be reduced (made smaller in size) while hydroceles cannot
  • Transilluminate: Hydrocoeles generally can transilluminate with a light while hernias look opaque

How the bowel gets stuck in the inguinal hernia

Figure 3

A painful non-reducible groin swelling associated with vomiting and constipation is an emergency and the child must to referred to a paediatric surgeon for reduction or surgery to prevent the bowel from getting strangulated.

Surgical Treatment of Hernias and Hydrocele

Treatment of inguinal hernias is surgery to prevent complications mentioned above. There is no role for any conservative treatment or bandages (Truss) to contain the hernia.

Image: US News

Hernias can be repaired by an open procedure or using laparoscopic (keyhole) surgery. In up to 15% of children, a hernia can also be found on the opposite side. Laparoscopy allows for the contralateral side to be examined and repaired at the same time using the same incision.

Hydroceles that persist beyond 3 years of age also need surgery. There is no role of aspiration of the hydrocele as they often recur or can lead to an infection.

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 Dr. Nada Sudhakaran

Dr. Nada Sudhakaran

Paediatric surgeon

 

Biliary Atresia

Biliary Atresia

Biliary Atresia is a progressive inflammatory fibrosis of the biliary tract and the disease starts in the extra hepatic bile ducts and extends into the intra hepatic ducts. Liver cells produce bile to help with fat digestion in the intestine. When bile cannot flow into the intestine, the bile builds up in the liver causing liver damage resulting in scarring and cirrhosis.

The incidence in Asia is around 1 in 10,000 – 20,000 live births. Some infants (around 10-15%) with biliary atresia have other congenital problems such as spleen abnormality (polysplenia), blood vessel anomalies or intestine mal-rotation.

Image Source: National Institute of Diabetes, Digestive and Kidney Diseases NIH

Symptoms
Prolonged jaundice can be normal in breast-fed babies however if there are signs of obstructive jaundice in a neonate, alarm bells should ring. Signs of obstructive jaundice are yellowing of the skin and whites of the eyes (sclera), pale coloured stools with dark coloured urine in an otherwise normal child. Infants with biliary atresia typically develop jaundice by 3 to 6 weeks of age.

Image Source: Fotolia

An infant with jaundice and pale stools should be referred to a paediatric surgeon urgently. The serum liver function test is usually abnormal. Typically, with biliary atresia, the conjugated fraction of serum bilirubin is more than 20% of the total serum bilirubin. (although the bilirubin total may not be extremely high).

Tests
Ultrasound scan may show fibrosis of the extra hepatic biliary tree and liver biopsy.  A cholangiogram (a dye injected into the gall bladder with an X-ray to see the flow of the dye in the liver) will give the definitive diagnosis.

Treatment

Image Source: US News

Surgical management for biliary atresia is the Kasai porto-enterotomy procedure to re-establish bile flow out of the liver and into the intestine.  The outcome for biliary atresia surgery is correlated to the timing of surgery. The earlier the procedure (ideally before 60 days), the better the rate for survival of the child’s own liver. The success of the procedure also depends on how damaged the liver is at the time of surgery and the number of viable ducts left in the liver to drain the bile. Some infants unfortunately, may still need a liver transplant later on in life.

In addition to surgery, the infant needs careful supervision of daily diet to include:

Image Source: Parents

  • Well balanced diet
  • Vitamin supplements
  • Addition of medium chain triglyceride (MCT) oil to the diet to add extra calories
  • High calorie liquid feeding if the infant is too ill to eat normally

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 Dr. Nada Sudhakaran

Dr. Nada Sudhakaran

Paediatric surgeon

Hypospadias

Hypospadias

Hypospadias is a congenital birth defect whereby the opening of the urethra (where the urine comes out off) is on the underside of the penis instead of the tip (see image). It is quite common affecting 1 in 150 to 250 males at birth and is the 2nd most common birth defect of the male urological system. Sometimes, it is associated with an undescended testis.

Symptoms & Signs
There is usually NO pain but there is abnormal spraying during urination because the urethral opening in on the underside of the penis. Sometimes, the penis has a downward curved (chordee) look or a hooded appearance because only the top half of the penis has a foreskin.

Treatment
Surgery is required to reposition the urethral opening and close off the abnormal one. It is best done between the ages of 6 to 12 months. Treatment is required because it may affect sexual function later on in life (such as erection or ejaculation) as well as toilet training. Sometimes, the penis also needs to be straightened during the surgery and also the foreskin repaired. Success rate is over 90% although some may need a 2nd surgery at a later date.

Reference: Mayo Clinic

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 Dr. Nada Sudhakaran

Dr. Nada Sudhakaran

Paediatric surgeon

Painful Testicle in Children (Acute Scrotum)

Painful Testicle in Children (Acute Scrotum)

Testicular pain known as acute scrotum can occur with or with our scrotal swelling or in the absence of redness. The common causes in children are as follows:

  • Torsion of epididymis or appendix of testis (60%)
  • Torsion of testis (30%)
  • Idiopathic scrotal oedema (< 5%)
  • Epididymitis or orchitis (< 5%)
  • Tumour
  • Trauma

Image Source: Sutter Health

In all cases of acute scrotum, it is IMPORTANT to bring the child to see a paediatric surgeon as soon as possible as the testicle may die of ischemia (lack of oxygen) is the case of a testicle torsion if left untreated for more than 6-8 hours.

Torsion of the epididymis or appendix of testis
The epididymis or appendix of testis are embryonic remnants of the fallopian tube during the development of the child. These can cause torsion and the pain is felt at the upper pole of the testicle.

Torsion of the testis
Torsion of the testis affects 1 in 4,000 men. It is more common in boys who have a testicle which lies horizontally (as opposed to vertically in normal cases) known as a Bell clapper deformity. This position allows the testis room to twist around its spermatic cord causing severe pain and nausea or vomiting. It can occur at any age but more commonly between 12-18 years. Sometimes it can occur after a sports injury to the groin. This a medical emergency and requires prompt treatment.

Torsion of the testis can also occur in undescended testicle which will be felt as a tender lump in the groin.

Idiopathic Scrotal Oedema
There is swelling and redness on both scrotum with oedema but no pain.  The cause is not known but thought to be due to allergic reaction to insect bites.  Clinical examination and ultrasound test is required to make a diagnosis.  No surgery is required as the condition subsides within 2-4 days with medication such as anti-histamine.

Epididymitis
Epididymitis is due to infection from retrograde flow of bacteria from the urine (reflux) from the urethra. The epididymis is the coiled duct behind the testicle which carries the sperm. The child usually has fever or pain when passing urine with positive bacteria culture in the urine test. Antibiotics may be required to treat this condition.

Tumour
The most common tumour in the testicle is a teratoma which is hard and painless. There may be a family history of teratoma or a history of undescended testis. Clinical examination, ultrasound and MRI can differentiate a tumour from a torsion of the testis. Treatment is a combination of surgery and chemotherapy. Prognosis is good if the tumour is discovered early.

Reference: Cancer Research UK

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 Dr. Nada Sudhakaran

Dr. Nada Sudhakaran

Paediatric surgeon

First Foods in Babies: How to Wean Your Child

First Foods in Babies: How to Wean Your Child

There is no right way and no right time to wean your baby. The most important point is that the journey is smooth and stress free for both of you, taking one step at a time. Do not worry that the maternal bond may be disrupted if the baby stops breast feeding because there are many other ways to stay close to your baby. Here are some tips to get you ready for the transition.

Image Source: Mother Baby & Child

When should I start weaning my child?

The UK Department of Health recommends that the babies should not be weaned until they are 6 months old while the American Academy of Paediatrics recommends that mothers breastfeed for at least a year.  However, more and more health professionals now agree that introduction of foods other than milk can begin from the age of 17 weeks as the baby’s digestive system is fully matured by then.

How should I wean my child?

There is no right or wrong way to wean a child. You can choose the method to wean when you feel that the time is right to do so. It normally feels quite natural; you will know it.

Baby-led weaning is the easiest way because your child begins to lose interest in breastfeeding which can start from 6 months onwards. By 12 months, most babies may show preference to solid foods. In fact, the more active they are, the faster they wean off breast milk. These are the signs that your baby is ready for solids:

  • Baby is curious and looking at you
  • Baby is interested in what you are eating
  • Baby can hold up the head
  • Baby is drooling

Image Source: New Kids-Center

Mother-led weaning is usually due to mother returning to a busy schedule such as work or other house chores: In this case, it is recommended that you can wean the baby off the breast gradually introducing a combination of bottle feeding breast milk, formula milk and solid food.  It takes time and patience to see how your baby adjust to the change.

It is best to go slow and go in stages. For example, try by skipping a feed and see what happens. You can substitute the feed using pumped breast milk, formula milk or solid foods.  Cow’s milk should only be given if your child is at least 1 year old.

Reducing feedings one at a time over a period of weeks gives your child time to adjust. Your milk supply also diminishes gradually this way, without leaving your breasts engorged or causing mastitis. Shorten nursing time and start by limiting how long your child is on the breast. If your child usually nurses for ten minutes, try five minutes.

What should be the first foods?

There should NOT be any added sugar, salt, nuts or honey for the first 12 months of life.  Start with single flavour food puree such as baby rice, vegetables (such as squash, pumpkin, sweet potatoes and yam) or fruits (such as apples and pears) for a stretch of 3-4 days.  After 4-6 weeks, you can mix these flavours together.

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Basic First Aid Tips for Parents

Basic First Aid Tips for Parents

Every child will definitely experience some falls and minor accidents while growing up. Here are some simple first aid techniques that every parent should know learn in case of emergency.

Open wound with bleeding (usually from cuts)

All wounds will stop bleeding with time as they will form a clot. Clean under running water and then use a clean cloth to press over the wound for a few minutes.  When the bleeding has stopped, apply antiseptic lotion or antibiotic cream and cover with a plaster if the wound is small. Larger or deeper wounds especially if the skin edges are jagged, need to be stitched by a trained doctor to prevent infection and poor healing causing unsightly scars.  If the cut is from a dirty metal object or animal bite, you will need a tetanus injection from your doctor (if you have not been vaccinated before) and antibiotic to prevent skin infection.

Apply antibiotic cream or change the plaster every 2-3 days until fully healed.  Do not pick at the scab as it delays healing.  Try to avoid the sun as the newly formed skin is more sensitive to being sun burn.  If the wound looks red, tender or has pus, see a doctor as soon as possible because this suggests that the wound has infection.

Image Source: The Asian Parents

Swelling or bruise (usually from blunt trauma or from a fall)

Most blunt trauma results in a swelling (due to inflammation) and bruising (if there is internal bleeding). Quickly apply cold compression (using ice cubes wrapped with a clean cloth) around the area to reduce the amount of the swelling and bruising.  Do NOT rub the area as it will make the swelling worse.

Image Source: One Three

Sprained ligament (usually the ankle, wrist or thumb)

A sprain is an injury to the ligaments which connects and hold the bones in place. It causes pain and swelling very quickly but fortunately, recovers within 1-2 weeks.  Follow the acronym RICE (Rest, Ice, Compression & Elevation). Rest the limb, apply ice pack compression and elevate the affected limb to reduce the swelling.  The ice pack can be applied for 15-20 minutes each time and repeated 4-8 times a day. Most important is NOT to move or weight bear on the leg. If injury looks worrying, go to a hospital emergency department to rule out a fracture by having an X-ray done.

Danger signs of sprains for which you need to see an orthopaedic doctor:

  • Inability to weight bear on the injured leg (or hand) or the joint feels unstable (suggestive of completely torn ligament)
  • A pain directly over the bone of an injured joint (suggestive of fracture)
  • Redness, swelling and hot over the area suggestive of infection

Possible fracture

Image Source: Operational Medicine

  1. For arms, apply an arm sling. You can make one by folding a large piece of clean cloth (such as a sarong or towel) into triangular shape and tie into an arm sling to support the arm.
  2. For legs, reduce movement and avoid weight-bearing on the affected leg. Elevate the leg.

In both cases, take some pain relief such as paracetamol and go to a hospital emergency department as soon as possible.

Burns or scalds

Get the child away from the heat source immediately and put the affected area under cold running water for 10-15 minutes to cool it down. This will prevent deeper and more severe burns. Remove any clothing but do not peel anything that may be stuck to the skin. Seek medical attention if the burnt area is large or deep.

Don’t pop any blisters yourself but let them heal naturally. If the skin breaks, apply an anti-biotic cream and cover the area with a bandage or gauze until it’s healed. Watch for any redness, swelling, tenderness or pus discharge which are all signs of infection.

Seizures

Lay the child down gently onto the floor and clear the surroundings from any hard or sharp objects that may cause injury. Lie the child to one side to allow any vomit or saliva to dribble out and prevent choking. Loosen any clothing around the neck. Do not attempt to put anything inside the mouth as it may cause further injury. Monitor breathing and seek medical attention if it is the first episode of seizure or if the seizure lasts more than 5 minutes.

Choking

Image Source: Active Moms Network

If the child is choking, the first thing you would notice is the child suddenly starts coughing. You may hear wheezing in between the coughs. They may clutch their throat with their hands. They may not be able to speak or cry. If the condition worsens, the child’s lips may turn blue and lose consciousness. If they are coughing, encourage them as it may dislodge the object. Do not leave them alone. You may attempt to remove the object only if you can see it clearly.

There are Basic Life Support (BLS) steps that can be done to help a choking child. These steps are taught during BLS courses along with CPR techniques in accordance with the American Heart Association guidelines.

There are two techniques that can be performed depending on the age of the child and is divided into infants (less than 1 year old) and child (over 1 year old).

Infant technique (back slaps and chest thrusts)

  • Sit down/kneel and place the baby in your lap with the face down and head slightly lowered
  • Hold the head and jaw with your hand while the body rests on your forearm
  • Rest your forearm onto your thigh for support
  • Give 5 back slaps in between the shoulder blades using the heel of your other hand. Do it forceful enough to dislodge the object

Image Source: Uma Mae

  • If unsuccessful, turn the baby around and hold the back of the head with your other arm and sandwich the baby between your arms. Turn the baby over while ensuring the head and neck is fully supported
  • Now rest the baby onto your forearm, facing up but head slightly lower along your thigh
  • Give 5 chest thrusts at a rate of 1 per second. Push downwards at the lower half of the breast bone, again, forceful enough to dislodge the object
  • If still unsuccessful and baby is still conscious, turnover the baby again and deliver another 5 back slaps
  • Repeat these steps until the object is dislodged

Child technique (Heimlich manoeuvre same as for adults)

Image Source: Mckesson Corporation

  • Stand/kneel behind the child so that you can wrap your arms around their waist.
  • Make a fist with your hand (usually left hand with the thumb enveloped by the other fingers)
  • Place it with the thumb side against the abdomen, at the soft area between the navel and the lower border of the breastbone.
  • Wrap your other hand around your fist.
  • Give a quick, forceful thrust in an inner, upwards direction. Forceful enough to dislodge the object.
  • Repeat these steps until the object is dislodged.

If the above fails, call for help. Dial 999 (or 911) and ask for an ambulance in a composed manner. State your address or location with any obvious landmarks. State what the emergency is and inform if it is an adult or a child. Afterwards, perform CPR while waiting. If there is another person around, tell them to call for an ambulance while you perform CPR. Tell them to get back to you to confirm that they have called the emergency services. If possible, ask them to bring an Automated External Defibrillator (AED) which should be available in major shopping malls or office buildings.

Image Source: Pixabay

Prevention is always better than cure

Children like to explore their surroundings and tend to put small objects (such as marbles or beads) into their mouth, nose or ears. Therefore, ensure their surroundings are free from these objects or else keep them at a higher place where they cannot reach. Always keep your surroundings clean and tidy.

During bottle feeding time, do not leave your baby unattended even for a few seconds. You may get distracted and take longer than anticipated which could raise the possibility of an untoward incident happening. Try not to feed your baby when you are sleepy. Check their solid food for any large or hard food sizes or fish bone before feeding them.

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Dr. Mohd Ridzuan Razak

Dr. Mohd Ridzuan Razak

General Medical Physician

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