Imperforate Anus

This is a congenital anomaly where the rectum ends in a blind pouch and you might have an opening into the vulvovaginal area in females and urethra in males. This is considered a disorder which have occurred during embryogenesis in the hindgut. This occurs in 1 in 5000 livebirths with slight male preponderance. This are classified into two kinds a low lying and a high lying rectal pouch. The experts use the pubococcegeal line as a guide to determine if the lesion is high or low. High lesions usually come with an underlying fistula wither rectourinary or rectovginal fistula.

Symptomatology
This is present at birth and the first things that happens is that you would not notice stools in the first 24 hours and this could be associated with abdominal distention. In some cases where there is a fistula you can see the stools and the urine seem to come in the same opening. If you notice this the first thing to do is transfer the baby at a pediatric surgical center,do not feed the baby temporarily then administer IV fluids and IV antibiotics specially when there is a fistula through the urinary tract. We worry about t a urinary tract infection.
Diagnosis
Diagnosis can be done with a combination of physical examination and and x-rays.
this is associated with the VACTERL syndrome (vertebral anomalies, anal atresia, cardiac problems, Tracheoesophageal fistula, renal problems and limb abnormalithes.

Treatment
Need to watch for constipation as the child grows bigger and to take care of this problem medically. The surgeon is consulted for anoplasty and serial dilations will be done. colostomy is done for high lesions.

Puberty is the product of Change

This is a stage in ones life that changes occur rapidly. Between early childhood and 8-9 years
of age the part of the brain that secretes the sex hormones are dormant. After this stage the hormones start to secrete and produce its effect. The onset of puberty is more related to skeletal maturity than to chronological age.

In girls, the breast bud is usually the first sign of puberty (10-11 year)
followed by the appearance of the pubic hair 6-12 months of age later and menarche will
follow between 2-2.5 years but may take as long as 6 years, In the United States the
peak age of menarche is 12.75 years old. There are however a wide variation in the stages
of development.

In boys, the first sign of puberty is testicular enlargement. Pubic hair then appears.
Growth acceleration in boys occur 2 years after the girls but can still continue till they are 18 years old. The pattern of sexual development follows parent's genetic pattern. If both parents develop early the chances that the children will also develop early is a highly likely.

What is considered pubertal delay?

• no signs of pubertal development by age 14 years old, in girls
• greater than 5 year interval between thelarche (breast development) and adrenarche (pubic and axillary hair development) in girls
• no signs of testicular enlargement by age 14 years old
• greater than 5 years for genital development
• primary amenorrhea no menarche by 16 years old with presence of secondary sexual characteristics
• primary amenorrhea no menarche by 14 years old without secondary sexual characteristics

What is defined as precocious puberty?

• traditionally defined as any sign of secondary sexual maturation before 8 years old in girls and 9 year old in boys

**recent data suggest early puberty may not even warrant extensive work-up if it occurs after 6 years old in African American girls and after 7 years old in white girls**

Protect your child from the Sun's rays

The temperature has been heating up again here in Arizona. The scorching heat went up to 110 degrees F last weekend and we can not but re-emphasize to everyone the importance of sun protection. It has been tempting to go dip in the pool during the middle of the day but that sun's rays are at its peak at this time

According to the American Academy of Pediatrics the sun's invisible ultraviolet rays are what cause damage to your child's skin even on foggy or hazy days . Hats and umbrellas do not completely protect children because UV lights reflect off the sand, water and other surfaces.

To protect against sun damage the AAP offers the following suggestions:

• Keep children away from the sun between 10am to 4pm
• use sunscreen with a sun protection factor(SPF) of at least 15. Apply 30 minutes before going outside and reapply every 1.5 to 2 hours especially while in water
• dress your child in a light cotton outfit with long sleeves and long pants and a wide brimmed hat
• use a beach umbrella to keep the child in the shade
• keep babies under 6 months of age away from the sun. Sunscreen maybe used in small areas of the body such as the face and the back of the hands
• the skin is not the only thing that needs protection but sunglasses are very important to protect your eyes

HAVE A SAFE AND FUN SUMMER!!

The Importance of Immunizing your Child

Please take a look at the link from the American Academy of Pediatrics on the Importance of immunizing your child and following th recommended schedule. www.ProtectTomorrow.org.

Periorbital cellulitis and Orbital cellulitis

Postorbital cellulitis

Periorbital cellulitis

Periorbital or preseptal cellulitis is the inflammation of the eyelids and the other soft tissues outside the orbit. This can be caused by trauma, or by an infected wound or an abscess in the lid. This can also be caused by a stye, conjunctivitis, infected blocked tear duct and insect bite. The most important thing to consider is to differentiate this with orbital cellulits which involves the inflammation of the tissues of the orbit with proptosis and limitations of eye movement. Sometimes it is hard to differentiate the two especially when the eyes are really swollen and it is hard to examine the movement of the eye. We then order a CT scan of the head and the orbits to determine if there is extension in the orbits. Orbital cellulitis follows a direct infection from a wound, deposition of organisms from the eyelids, conjunctiva, metastatic involvement from a tumor. The most common cause in children is paranasal sinusitis. Orbital cellulitis have complications which result in meningitis and cerebral abscess . Prompt hospitalization with intravenous antibiotic therapy and surgical drainage of the infected sinuses are part of the treatment.

Ventricular Septal Defect (VSD)

VSD is the most common congenital anomaly of the heart and it accounts for 15-25% of congenital heart disease. This is described as a "hole in the heart". The heart is made of 4 chambers the right and left atrium on top of the right and left ventricles. Unoxygenated blood comes from all the body and is channeled into the right atrium this then goes to the right ventricle and this gets oxygenated through the lungs then passes the left atrium to the left ventricle and this becomes oxygenated blood that gets distributed through the aorta to the rest of the body. The VSD is basically a hole in between the chambers of the ventricles that result in mixing of the oxygenated and unoxygenated blood.

Usually for the first few weeks of life a heart murmur can be heard by your doctor and most of the babies will be asymptomatic especially when the VSD is small. In some cases when the VSD is moderate or large the babies will not be gaining enough weight. They will be breathing faster than usual and sometimes their color looks dusky from time to time.

Treatment:
Small VSD usually close over time. This will be followed-up by the baby's cardiologist Moderate to large VSDs might need surgical intervention but they do not do the surgery till the baby is about 6 months of age. They want the baby to be gaining enough weight by giving them a high caloric diet at 24 to 26 kcal per ounce and putting some feeding tube to help them gain weight.They also start them on some diuretics or heart medicine to help maintain them and try to control their symptoms.

The great thing about this ventricular septal defects is that most of them resolve on its own and it is easily correctable by surgery.

What is Bell's Palsy?

The chief complaint that you would hear most of the time would be "one side of my child's face does not seem to be moving, this is more noticeable when he cries, laughs or screams". The child will be unable to close the eye on the affected side and the corner of the mouth will droop. This is considered a common disorder in infancy to adolescence. Taste on the front of the tongue might be lost but there should be no numbness to the area. The most important thing you want to prevent is dryness of the affected are which will result in keratitis. Your doctor will prescribe some eye drops to prevent this from happening. The facial nerve on the affected side is considered to be swollen thus this symptoms appear.

The most common reason for this palsy is that the child had some type of viral infection approximately 2 weeks prior to the event. Most common cause is the Epstein-Barr virus, Lyme disease (you usually see this in the Northeast area), herpesvirus and mumps virus. This has excellent prognosis because 85% will resolve completely without residuals, 10% with very mild residual weakness and only 5% are left with severe facial weakness.

Steroids do not induce remission and is not recommended but since the pathophysiology is swelling of the facial nerve some people think that this might help a little bit. If palsy seems to be chronic or persistent you need to consider other facial nerve tumors that can impinge on the nerve to present with the symptoms. Physical therapy might help a little bit in the recovery process.